and Perinatal
                       death inquiry
                       and resPonse

EmpowEring communitiEs to avErt matErnal DEaths in inDia

unite for
“The most important reason
for lack of progress in reducing
maternal deaths is denial -
we need more openness and
clearer messages.”

Jens Stoltenberg, Prime Minister of Norway
At the launch of Tanzania’s ‘One Plan’ programme, April 2008

The current estimated maternal mortality ratio           UNICEF’s support to the MAPEDIR extends across
in India is 301 per 100,000 live births. This
                                                         select districts in Rajasthan, Madhya Pradesh, west
translates into about 80,000 pregnant women or           Bengal, Jharkhand, Orissa and Bihar. Across these six
new mothers dying annually often from preventable        states, the MAPEDIR has empowered communities
causes. The medical reasons for maternal deaths          to improve maternal health as well as influenced safe
find their roots in interlinked social phenomena         motherhood programmes at the local and state levels.
such as the low status of women in communities,          The power of this initiative is underscored by several
poor understanding of the families on when to seek       examples. It has led to a Community Based Obstetric
care, and inaccessibility of quality healthcare in       Referral Initiatives (Obstetric Helpline) in Rajasthan, a
rural areas. Although these social causes are more       district health system led initiative in Madhya Pradesh
difficult to document, they must be addressed if         and the design of a referral transport scheme in
we are to achieve the Millennium Development             west Bengal. As a result of the initiatives, thousands
Goal of reducing maternal mortality by three             of women with obstetric complications have been
quarters in 2015.                                        transported to quality healthcare in these states.
                                                         Many states have decided to broaden the outreach
UNICEF is committed to working with the national         of these initiatives that will in turn save the lives of
flagship programme, National Rural Health Mission,       many more pregnant women and new mothers.
to promote decentralised planning as a key strategy
to lower maternal and child mortality. It is important   This document seeks to capture some of this
to note that the success of decentralised planning       extraordinary work hoping that it will inspire the use of
rests on our ability to capture ground realities and     the MAPEDIR to mobilise communities and influence
feed this information back to communities and            programmes for safer motherhood everywhere. UNICEF
health systems for appropriate action. Since 2005,       remains committed to working for the development
UNICEF has supported the Maternal and Perinatal          and participation of the women and children of India.
Death Enquiry and Response (MAPEDIR) which is
a powerful tool that systematically captures the
ground realities of maternal deaths, analyses the
underlying medical, social and systemic factors and      Karin Hulshof
finally uses this evidence to generate community         Representative
and programme action.                                    UNICEF India Country Office

1 India SRS Sample Registration System 2003.

This working paper recognises the contribution       instruments from the Johns Hopkins Bloomberg
of frontline workers, doctors, district officials,   School of Public Health, Baltimore, USA.
self-help groups, NGOs, academicians and policy
makers towards reducing maternal deaths at the       This document would not have been possible
state and national level in India.                   without the valuable insights of Chief Medical
                                                     Officers, Public Health Nurses, lady Health Visitors
we are grateful to Mr Naresh Dayal, Principal        (lHVs), Auxiliary Nurse Midwives (ANMs), as also
Secretary, Health and Family welfare, Government     of the families who generously shared their time and
of India, who was the driving force that inspired    experiences, often under daunting circumstances.
Maternal Health to become the pivot of RCH II        Added to this, the enthusiastic support rendered
and the NRHM.                                        throughout by the UNICEF Health Team in the India
                                                     Country Office, State Representatives, Project
UNICEF is indebted to Mr Girish Chaturvedi,          Officers and field teams in Madhya Pradesh, Orissa,
NRHM Mission Director, Dr Aradhana Johri, Joint      Rajasthan and west Bengal, along with the inputs
Secretary at MOHFw-GOI, as also Dr Namshum,          provided by staff in Bihar and Jharkhand and by the
Dr Manisha Malhotra and Dr Himanushu Bhushan         UNICEF Advocacy and Partnership Section in Delhi,
of the Maternal Health Division of MOHFw, for        were equally vital for the successful completion of
their support and guidance for key inputs in the     this document.
preparation of this document.
                                                     Active contribution of UNICEF staff members
UNICEF also appreciates the collaboration and        Dr Gaurav Arya, Dr Marzio Babille, Dr Sudha
efforts of the Government of Rajasthan, especially   Balakrishan, Dr Narayan Gaonkar, Dr Gagan Gupta,
Ms Shubhra Singh, Secretary Health and Family        Dr Kaninika Mitra, Dr Pavitra Mohan, Naysán Sabha,
welfare, Dr SP Yadav, Director, Reproductive         Dr Anju Puri, Dr Ashish Sen, Dr Khynn win win
Child Health, and Dr Yogiraj Sharma, Director,       Soe and Dr Jorge Caravotta was very valuable in
Public Health and Family welfare, Government         development of the document.
of Madhya Pradesh.
                                                     The significant contribution of Ms Patralekha
UNICEF is immensely grateful for the technical       Chatterjee, an independent writer on public health,
guidance provided throughout by Dr Henry             is gratefully acknowledged towards the research,
Kalter, an international expert on verbal autopsy    text and photographs in this working paper.

Acronyms                                                                2

Executive Summary                                                       3

Background                                                              6

Introduction                                                            7

Chapter 1: Unseen under the Spotlight                                  12

Chapter 2: MAPEDIR: A Community Empowerment Instrument                 22

Chapter 3: The First Battleground                                      30

Chapter 4: MAPEDIR in Action - Madhya Pradesh, Orissa, and Rajasthan   46

Chapter 5: Obstacles, Opportunities and Mapping the Road Ahead         66

Annexures                                                              73

ANC     :   Ante Natal Care                         LHV     :   lady Health Visitor
ANM     :   Auxiliary Nurse Midwife                 MBBS    :   Bachelor of Medicine, Bachelor of
APH     :   Ante Partum Haemorrhage                             Surgery
ASHA    :   Accredited Social Health Activist       MCH     :   Maternal and Child Health
AWW     :   Angan wadi worker                       MDG     :   Millennium Development Goal
BDO     :   Block Development Officer               MDI     :   Maternal Death Inquiry
BPHC    :   Block Primary Health Centre             MMR     :   Maternal Mortality Ratio
BPL     :   Below Poverty line                      MOHFW :     Ministry of Health and Family welfare
CDMO    :   Chief District Medical officer          MPW     :   Multi Purpose worker
CEMONC :    Comprehensive Emergency Obstetric       NHRM    :   National Rural Health Mission
            and Newborn Care                        NFHS    :   National Family Health Survey
CMHO    :   Chief Medical Health Officer            NGO     :   Non-Governmental Organisation
CHC     :   Community Health Centre                 NPP     :   National Population Policy
DFID    :   Department for International            PHC     :   Primary Health Centre
            Development (a department of the UK     PRI     :   Panchayati Raj Institution
            Government responsible for promoting    PPH     :   Post Partum Haemorrhage
            development and reducing poverty)       PPTCT   :   Prevention of Parent to Child
DPM     :   District Programme Manager                          Transmission
EOC     :   Emergency Obstetric Care                RCH     :   Reproductive and Child Health
FRU     :   First Referral Unit                     RGI     :   Registrar General of India
GOI     :   Government of India                     RHS     :   Rapid Household Survey
GOWB    :   Government of west Bengal               RMP     :   Registered Medical Practitioner
ICDS    :   Integrated Child Development Services   SBA     :   Skilled Birth Attendance
IEC     :   Information Education Communication     SC      :   Sub-Centre
IFA     :   Iron Folic Acid                         SHG     :   Self-Help Group
IIPS    :   International Institute of Population   SRS     :   Sample Registration System
            Sciences                                TOT     :   Training of Trainer
IMCI    :   Integrated Management of Childhood      UN      :   United Nations
            Illness                                 UNICEF :    United Nations International Children’s
IMNCI   :   Integrated Management in Neonatal                   Emergency Fund
            and Childhood Illnesses                 UP      :   Uttar Pradesh
IMR     :   Infant Mortality Rate                   VHW     :   Village Health worker
JSY     :   Janani Suraksha Yojana                  WHO     :   world Health Organisation


The global maternal mortality ratio (MMR) remains          Poor, powerless and pregnant women remain
unacceptably high. worldwide, nearly half a million        amongst the most vulnerable members of society.
women die each year from complications during
pregnancy and childbirth. About 99 per cent of these       For far too long, the magnitude of the problem of
women belong to the developing world, with over            maternal mortality remained unclear to policy makers
90 per cent concentrated in Africa and Asia. The tragedy   because such deaths in many instances remained
is that almost every one of these deaths was avoidable.    ‘invisible’. As in other developing countries where
                                                           many maternal deaths are unrecorded, statistical
Although some developing countries have shown              estimates in India too tell only part of the story. Very
progress, proving that given the required political        often, no one knows how or why the women died.
will and commitment, reductions are possible within
existing resources, India has yet to meet the world’s      The recognition that these deaths are not just
expectations in lowering maternal mortality risks to an    unfortunate but unnecessary has come with better
acceptable level. The Government of India estimates        understanding among policy makers and public
India’s MMR currently at 301 per 100,000 live births       health practitioners of what contributes to maternal
(RGI: 2001-03 Maternal Mortality Report), down from        mortality. Globally, there is evidence that most
407 per 100,000 live births in 1997-98. Even so,           maternal deaths can be averted but for the ‘three
across the country, more than 80,000 women die             delays’ – (i) delay in decision to seek professional
annually while pregnant, at childbirth, or soon after.     care, (ii) delay in reaching the appropriate health
                                                           facility, and (iii) delay in receiving care after arriving
Given India’s vast size and socioeconomic diversity,       at a hospital. Tackling and averting this trio of delays
national averages camouflage the vast differences          will help the world as also India to reduce the burden
between states and regions, town and country, and          of maternal mortality.
also between the poor and rich. Recent estimates
suggest that two-thirds of maternal deaths in              In 2008, as the world takes stock of the progress
India occur in a handful of states – Assam, Bihar,         and challenges in tackling issues surrounding safe
Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa,           motherhood, there is good news from India, a
Rajasthan, Uttaranchal and Uttar Pradesh.                  country with one of the highest number of maternal
                                                           deaths. India is taking initiatives, which if successful,
It is an unfortunate fact that despite impressive          could decrease maternal mortality across the
economic growth in the rural hinterland where lives        developing world. Among other issues, Maternal,
the vast majority of the Indian population, female         Newborn and Child Health (MNCH) are now
health indicators have not yet changed noticeably.         moving up the country’s policy agenda. Also, Safe

Motherhood is a top priority of the country’s National   childbirth, and 24x7 emergency obstetric care to
Rural Health Mission (NRHM) launched in 2005.            deal with different levels of complexity.

Significantly, district administrations no longer        The MAPEDIR initiative puts in place a process that
cite resources as a key constraint. Health service       uses a confidential inquiry tool to examine maternal
providers are attending training sessions to hone        deaths, generate local evidence, sensitise communities
their skills and improve their knowledge base. Skilled   and health officials, and galvanise them into taking
Birth Attendants are getting trained, Primary Health     action to reduce such deaths. The new knowledge
Centres are being upgraded and First Referral Units      stemming from the scrutiny of maternal deaths in rural
(FRUs) getting vitalised. Also, efforts are underway     areas bridges a crucial gap. Typically, medical records
to expand the cadre of skilled birth attendants and to   capture only the immediate, biological causes of
tone up facilities for emergency obstetric care. These   maternal deaths. The personal, familial, socio-cultural,
efforts are focused on 18 states with weak public        economic and environmental factors contributing to
health indicators and/or weak infrastructure.            these deaths are left out. MAPEDIR seeks to restore
                                                         and record these missing links.
Titled ‘Maternal and Perinatal Death Inquiry and
Response ‘(MAPEDIR), this more recent initiative,        Piloted in Purulia, one of the poorest and most
incorporates the best practices and concepts from        backward districts of west Bengal in June 2005,
within India and elsewhere and attempts to translate     MAPEDIR is currently implemented in 16 districts in
them into action at the community level – sparking       six Indian states with high maternal mortality. These
genuine change in understanding and tackling             are: west Bengal (Purulia); Rajasthan (Dholpur, Tonk,
maternal mortality at the family, community, health      Udaipur); Jharkhand (Ranchi); Madhya Pradesh (Guna,
service, and policy-making levels.                       Shivpuri); Orissa (Nuapada, Koraput, Kalahandi,
                                                         Bolangir, Sonepur, Malkangiri, Nabarangpur, Rayagada;
MAPEDIR’s genesis lies in UNICEF’s Maternal              and Bihar (Vaishali). It is also in the process of being
Mortality Reduction Advocacy Project, supported by       rolled out in Maharashtra and will be implemented in
the United Kingdom’s Department for International        Assam and Haryana before December of 2008.
Development (DFID).
                                                         Over the past two years, trained in the MAPEDIR
The MAPEDIR initiative underscores the need for          process, health and community workers and NGO field
information about the underlying causes of maternal      staff have visited families where a maternal death took
deaths in remote and inaccessible villages. It grew      place. The findings from their structured questionnaire
out of UNICEF’s decision to support maternal             (translated into the local language), enquiring minutely
death inquiry as a component of the ongoing              into the circumstances of the maternal death, have been
second phase of the Reproductive and Child Health        widely shared with communities and with local health
Programme (RCH II) and the unfolding National Rural      authorities, leading to a gratifyingly active response.
Health Mission. RCH II emphasises on increasing
the demand for quality healthcare and for greater        Beginning on a small scale in some districts,
community participation in the planning of public        MAPEDIR is now gaining wide acceptance as a viable
health interventions, while NRHM focuses on              strategy for preventing maternal deaths by offering
the imperative of making available Accredited            much needed data. One of the most heartening
Social Health Activists (ASHAs) in every village         indicators of its success is community-initiated
as mobilisers, skilled attendants at the time of         action to ensure safe motherhood. There is greater

awareness about the factors leading to maternal              scheme for Below Poverty line women, the Janani
deaths as well as the relevance of birth-preparedness        Suraksha Yojana (JSY) in rural communities. Even
and complication-readiness. There is also greater            in tribal-dominated districts where community
willingness to contact and demand service from the           structures may be lacking, MAPEDIR is acting
healthcare delivery system. These are revolutionary          as a catalyst and serving as an alert mechanism.
ideas for rural, remote Indian communities that              Households deprived of education and other basic
previously had minimal interface with the healthcare         amenities are beginning to realise that delays at
system. For instance, in Purulia, the referral initiative    critical junctures can lead to maternal deaths. In
conceived by village leaders in one of the blocks            many cases, the arrival of MAPEDIR interviewers
is saving lives. In Dholpur (Rajasthan), village-level       in a village has sparked a sense of urgency among
transporters have become part of the movement to             local authorities to modernise maternal care facilities
reduce maternal deaths. These are but two examples           by using Rogi Kalyan Samiti funds made available
of the dynamic potential and promise of MAPEDIR.             by the National Rural Health Mission. The tool has
                                                             also underscored the need for better reporting of
At the institutional level, the MAPEDIR process              maternal deaths in states with weak healthcare
has spawned new strategic partnerships between               systems and infrastructure.
government agencies, NGOs, academic institutions and
the UN system. A collaborative initiative, it has elicited   As India takes determined strides towards achieving
the involvement of several key institutions and groups       the fifth Millennium Development Goal of 109
including the Government of India, State Governments,        maternal deaths per 100,000 live births by 2015,
District Administrations, Panchayati Raj (village-level      this working paper provides powerful evidence for
institutions), women’s self-help groups, local non-          advancing the MAPEDIR movement to save mothers
governmental organisations (NGOs), medical faculties of      and their children both within the country and
Indian universities, the Johns Hopkins Bloomberg School      beyond. It also looks at the challenges that remain.
of Public Health (USA), wHO, UNFPA and UNICEF.               If best practices from the MAPEDIR-implementing
                                                             districts are replicated more widely across the
The above links are generating greater awareness of          country, India and the world will move closer to
existing government facilities and schemes for safe          the target of a 75 per cent reduction in maternal
motherhood such as the conditional cash transfer             mortality by 2015, as set out in MDG5.

   » Piloted at Purulia (West Bengal) in June 2005, MAPEDIR is currently implemented in 16 districts in six
     Indian states with high maternal mortality.
   » The MAPEDIR tool, a detailed verbal autopsy questionnaire, captures missing links in officially recorded
     data so as to reconstruct the sequence of events and pinpoint the exact cause of a maternal death.
   » The MAPEDIR initiative sensitises communities and health officials to issues concerning maternal health
     and galvanises them into taking long-term action to reduce maternal deaths.
   » At the institutional level, the MAPEDIR process has spawned new strategic partnerships between
     government agencies, NGOs, academic institutions and the UN system.
   » MAPEDIR marks the beginning a powerful movement to help India achieve its MDG5 of 109 maternal
     deaths per 100,000 live births by 2015.


The International Safe Motherhood Conference at        The ministers and parliamentarians also pledged
Nairobi in 1987 was a landmark event. For the first    to be advocates in their home countries for
time ever, the international development community     “increased commitment of financial and human
focused on one of the most neglected issue of our      resources” against maternal mortality and to
times – the plight of women dying in pregnancy         accelerate the expansion of services for maternal
and childbirth. The Safe Motherhood Initiative,        and newborn health.
launched in Nairobi, aimed to halve maternal
deaths by the year 2000. The initiative triggered      In India, MAPEDIR was introduced in June 2005.
significant changes in the thinking of policy makers   UNICEF partnered with governments, community
and practitioners, and made safe motherhood a key      institutions and academic faculties to pilot MAPEDIR
component of interventions focusing on women’s         in Purulia, one of the poorest districts in west
health and rights. In September 2000, the United       Bengal. Since then, the project has expanded to
Nations Millennium Summit set a target of 75 per       cover 16 districts in six states with high maternal
cent reduction of maternal mortality by 2015 in the    mortality. These are: in west Bengal (Purulia),
form of Millennium Development Goal 5 (MDG5).          Rajasthan (Dholpur, Tonk, Udaipur); Jharkhand
                                                       (Ranchi); Madhya Pradesh (Guna, Shivpuri); and
In ‘women Deliver’ conference held at london in        Orissa (Nuapada, Nabarangpur, Koraput, Malkangiri,
October 2007, more than 1,800 participants from        Rayagada, Bolangir, Kalahandi and Sonepur). Bihar
109 countries endorsing a final statement from         became the sixth state in India to launch MAPEDIR in
70 cabinet ministers and parliamentarians, pledged     June 2007. In 2008 it is being carried forward with
to make achievement of MDG5 “a high priority on        implementation in the states of Maharashtra, Assam
the national, regional, and international agendas.”    and Haryana.


“If new mothers thrive, it means that the healthcare                        MATERNAL MORTALITY: CAUSES
system is working, and the opposite is also true…”                          AND COMPLICATIONS
laurie Garrett, The Challenge of Global Health,
Foreign Affairs, January-February 2007
                                                                                Causes of maternal death, global
Most maternal deaths are preventable. Yet, more than                            Obstructed labour                                 11%
half a million women die each year around the world                             Eclampsia                                         16%
from complications of pregnancy and childbirth.2                                Unsafe abortion                                   18%
Although pregnancy is not a disease, it does pose                               Infection                                         21%
risks to the health and survival of a woman. These                              Haemorrhage                                       34%
risks vary in magnitude. The risk of a woman dying
                                                                            Source: wHO, 2005
because of pregnancy or childbirth ranges from one
in six in Afghanistan and Sierra leone, to one in 100                       In Asia, five direct complications account for
in India, and about one in 17,400 in Sweden. In the                         more than 70 per cent of maternal deaths in Asia:
developed countries, because every pregnant woman                           Haemorrhage (31 per cent), Sepsis/ infection
has access to special care, pregnancy and childbirth                        (12 per cent), unsafe abortion (6 per cent), Eclampsia
rarely lead to death or disability. This is not the case                    (very high blood pressure leading to seizures – 9 per
in many developing countries where each pregnancy                           cent), and obstructed labour (9 per cent).4 Severe
represents a journey into the unknown from which                            anaemia is a critical underlying factor and indirect
many women may never return.                                                cause of maternal deaths in India as in most parts
                                                                            of South Asia. Most maternal deaths occur between
Maternal loss impacts child survival irreversibly. One                      the third trimester and the first week after delivery.
million children are left motherless each year. These                       Studies further indicate that mortality was more than
children are 10 times more likely to die within two                         100 times higher on the first day and 30 times higher
years of their mothers’ death as compared to those
                                                                            on the second day after birth than in the second
who flourish in maternal love and care.                                     year postpartum. Mortality rates can be especially
                                                                            high after an abortion or stillbirth. while these are
In addition to maternal deaths, for every woman who                         the main causes of maternal death, the fundamental
dies in childbirth, around 20 more suffer injury, infection                 reasons are unavailable, inaccessible, unaffordable,
or disease – approximately 10 million women each year.                      or poor quality care (see Box 1).

2 Progress for Children-A Report Card on Maternal Mortality-Number 7, September 2008.
3 world Health Report 2005.
4 Khan, Khalid S, et al, “wHO Analysis of Causes of Maternal Death: A systemic review”, Lancet, Vol. 367, 1 April 2006, p.1069.

    Box 1: Tracking and tackling complications related to pregnancy deaths

    Globally, the most common complication leading to maternal death is post-partum haemorrhage (heavy
    bleeding after delivery). Sepsis, hypertensive disorders of pregnancy, especially eclampsia, complications
    of unsafe abortion and prolonged or obstructed labour claim further lives. These complications can occur
    during pregnancy and childbirth without forewarning. Some root causes for maternal risk can, however,
    be traced back to girlhood. In the developing world, chronic malnutrition stunts growth and severely
    malnourished women are vulnerable to obstructed labour. Anaemia puts a woman at risk of sepsis during
    delivery, and when haemorrhage occurs, she is less able to cope with the physiological stress. Under-age
    marriages and motherhood also make for risky childbirth. The factors that cause maternal morbidity affect
    the survival chances of the foetus and newborn, leading to an estimated 8 million perinatal deaths a year
    (over half of them foetal deaths) occurring just before or during delivery, or in the first week of life.5

    As demonstrated by a growing number of countries, skilled care at delivery backed up by referrals to
    timely emergency obstetric care is one of the key elements necessary to reduce maternal mortality.
    Eastern and South-Eastern Asia and Northern Africa have made the greatest headway, with increase in
    attended births of from 55 per cent to almost 80 per cent. But currently, only 46 per cent of deliveries
    in sub-Saharan Africa, where almost half the world’s maternal deaths occur, are assisted by skilled
    attendants. In Southern Asia, the proportion is even lower.

ASSESSMENT                                                    suggests that a reduction of 75 per cent in the
                                                              Maternal Mortality Ratio (MMR) is achievable within
Despite global concern, a key problem in tackling             a 25-year timeframe.
maternal mortality is how to accurately monitor
it and obtain reliable comparable data. Ascertaining          where significant reduction was achieved, it was
maternal mortality is notoriously difficult except where      done mostly through the provision of professional
there is comprehensive registration of deaths and             midwifery care at birth and improved access
causes of deaths. As most developing countries have           to hospital care. These measures enabled all
weak vital registration and health information systems,       industrialised countries to reach an MMR of
they cannot provide an accurate assessment of maternal        20 to 30 deaths per 100,000 live births as early
mortality. On the other hand, an estimate derived             as 1960. Many developing countries too, have
from the more complete vital registration systems
such as those in developed countries, suffers from
misclassification and under-reporting of maternal deaths.         Maternal Mortality Ratio (MMR) is defined as
                                                                  the number of maternal deaths per 100,000
                                                                  live births due to causes related to pregnancy
REDUCING MATERNAL MORTALITY                                       and within 42 days of termination of
                                                                  pregnancy, regardless of the site or duration
Reducing maternal deaths has been a slow process.                 of pregnancy.
Evidence gained from past experience globally

5 Lancet, Vol. 368, September 2006, p.1193.

shown impressive progress, albeit over varying                         reduce maternal mortality, and developing countries
time frames.                                                           do not have to wait for economic prosperity before
                                                                       they take steps to address the ongoing tragedy of
Thailand substantially reduced its MMR from more                       maternal mortality. The success of these countries
than 400 in 1960 to 50 in 1984. Malaysia and                           is attributed to a combination of factors including
Sri lanka also saw declines in MMR of over                             long-term investment in midwifery training and
50 per cent during the same period. Starting from                      referral hospitals; free healthcare and a supportive
a lower baseline ratio of less than 200, both Egypt                    system with regulation, control, and supervision
and Honduras halved their MMR in less than 7 years!                    of the medical and midwifery profession; and an
A substantial decline also took place in Matlab,                       effective monitoring mechanism to track progress.
Bangladesh where MMR dropped from around 600                           Much of this progress has gone hand in hand with
in 1976 to 200 in 2001. In contrast, sub-Saharan                       community and women empowerment.
Africa and some countries in South Asia with high
current levels of maternal mortality have shown
considerably less or virtually no progress.6                           UNSAFE MOTHERS IN INDIA

                                                                       India accounts for 23 per cent7 of the global burden of
    The United Nations Millennium Development                          maternal deaths based on latest available 2005 global
    Goals (MDGs) Report 2006 clearly states                            data. The current estimate of an MMR of 301 by the
    that though the issue has been high on the                         Registrar General India (2001-2003), translates to
    international agenda for two decades, ratios                       approximately 80,000 women dying each year due to
    of maternal mortality seem to have changed                         pregnancy related complications. Regional disparities
    little in regions where most deaths occur                          in MMR burden some states more such as Madhya
    (sub-Saharan Africa and Southern Asia).                            Pradesh, Rajasthan and Uttar Pradesh than others
    In developing countries, one in every                              (Kerala and Tamil Nadu) as seen in Table 1.
    11 women dies of pregnancy related
    complications compared to 1 in 5000
    in developed countries (wHO, 2004).                                SOME STARTLING STATISTICS

                                                                       •	 Every	5	minutes,	one	woman	somewhere	in	
GOALS ACHIEVABLE DESPITE                                                      India dies from complications of childbirth.
RESOURCE CRUNCH                                                        •	 15	per	cent	of	all	pregnant	women	in	India	
                                                                              develop life-threatening complications.
Being poor, powerless and pregnant is life                             •	 65	per	cent	deliveries	occur	at	home.
threatening. However, a decline in maternal                            •	 60	per	cent	of	all	maternal	deaths	occur	after	
deaths is achievable even in comparatively low-                               delivery but only 1 in 6 women receives
resource settings provided a country treats it as a                           postnatal care.
public health priority. As Cuba, Egypt, Honduras,
Malaysia, Thailand and Sri lanka have convincingly                     Embedded in pockets of deprivation, whether
demonstrated, a high GNP is not necessary to                           in the economically weaker states or population

6 Maternal Survival Series, Lancet, Vol. 368, September 2006.
7 Maternal Mortality in 2000: Estimates developed by wHO, UNICEF and UNFPA.

                                                            saying ‘No’ to maternal mortality will enable India
 Table 1
                                                            to overcome this ongoing tragedy. Timely detection
 India and Major States            Maternal Deaths    MMR
                                         (per year)         and effective management of the problems related
 Assam                                          96    490   to safe pregnancy and delivery are certain to help
 Bihar including Jharkhand                     156    371   lower India’s MMR, in turn enabling the world to
 Madhya Pradesh including                      104    379   achieve the targeted global reduction in maternal
                                                            risks and deaths. In that way, India seems uniquely
 Orissa                                         75    358
                                                            and significantly positioned to contribute to a global
 Rajasthan                                     140    445
 Uttar Pradesh including                       324    517   reduction in maternal deaths.
 Andhra Pradesh                                 37    195   Blessed with this window of opportunity, India has
 Karnataka                                      57    228   already taken significant steps. The National Rural
 Kerala                                         18    110   Health Mission (2005-2013) prioritises maternal
 Tamil Nadu                                     26    134
                                                            and child health. It offers incentives to families and
 Gujarat                                        37    172
                                                            health workers to encourage institutional deliveries.
 Haryana                                        28    162
                                                            The ongoing second phase of the Reproductive and
 Maharashtra                                    31    149
                                                            Child Health Programme (RCH II), which comes
 Punjab                                         20    178
 west Bengal                                    58    194
                                                            under the NRHM framework emphasises increasing
 INDIA Total                                 1,383    301   the demand for quality healthcare and for greater
 Source: SRS, 2001-2003                                     community participation in the planning of public
                                                            health interventions, especially in rural areas in the
groups, these huge disparities in MMR are                   economically underprivileged and under-performing
attributable to sharp differences in access to              states. RCH II also stresses the need for creating
skilled birth attendants, emergency obstetric care,         a decentralised evidence base for more focused
prenatal care, levels of anaemia, female literacy           planning and innovations in this field.
and other factors affecting the status of women.
Ranked among the five countries that have less
than 50 per cent deliveries assisted by skilled             TRACKING MISSING LINKS FOR NEW
attendants,8 India is a prime candidate for and             KNOWLEDGE
contributor to high MMR.
                                                            Since 2002, UNICEF has played an important
                                                            role in the generation of new knowledge that
WINDOW OF OPPORTUNITY                                       can contribute significantly to solving time-worn
                                                            problems besetting maternal and child survival in
Fortunately, there is growing realisation among policy      the country. It is working with the Government
makers that maternal death has been a ‘tolerated’           of India, State Governments, District
tragedy for far too long, and that most such deaths         Administrations and other partners to help
can be prevented. The resources are there, as are           demonstrate what works at the community and
innovative ideas to save the most vulnerable mothers        district levels, and to scale up interventions by
and children in remote, rural areas. Replicating            extracting lessons learned and framing them into
and disseminating good practices in addition to             inputs for policy development.

8 National Family Survey NFHS-3 2005-2007.

Building a reliable database and grasping the factors      contributed to the death of a pregnant woman. Using
underlying high maternal mortality are critical to         a verbal autopsy tool to support a community-based
reducing India’s high MMR. Existing data on the            social audit, MAPEDIR is identifying the underlying
incidence and trends in maternal mortality are             causes of maternal deaths in selected districts in
inadequate. Moreover, the data on maternal deaths          India since 2005. The evidence gathered through
gathered through the country’s vital registration and      MAPEDIR is now being used by policy makers and
health information systems are not able to capture         communities to develop initiatives that save mothers
the full scenario or “tell the whole story”, leading to    and children.
the loss or impairment of a pregnant woman’s life.
More detailed investigations are needed to identify        Each maternal death is a tragedy but the bigger
the underlying causes of these deaths and to find          tragedy is failing to learn lessons from an avoidable
out ways of dealing with them.                             maternal death. A systematic analysis of MAPEDIR
                                                           data provides both qualitative and quantitative
One of the most promising initiatives in this context      insights into the cause of death, its relationship
is MAPEDIR or Maternal and Perinatal Death Inquiry         to pregnancy, preventability and the contributing
and Response, which is a tested method of finding          problems. This information forms a guide to the
out the medical causes of death and ascertaining the       development of interventions and policy and action
personal, family or community factors that may have        at all levels.

   » The health and wellbeing of mothers and their newborns are true indicators of the efficacy
     of the healthcare system in a country.
   » India, with one of the highest MMRs of 301, accounts for 23 per cent of the half million maternal
     deaths worldwide.
   » Statistics recording the biological causes of maternal deaths fail to reveal the underlying personal,
     familial, socio-cultural, economic and environmental factors leading to them.
   » MAPEDIR or Maternal and Perinatal Death Inquiry and Response, initiated by UNICEF in 2005
     seeks to restore and record these vital missing links.
   » MAPEDIR is a standardised measurement and monitoring verbal autopsy tool which examines
     maternal deaths, generates local evidence, sensitises communities and galvanises health officials
     and policy makers into taking effective action to reduce such deaths.
   » Decline in maternal deaths is achievable even in comparatively low-resource settings provided a
     country treats it as a public health priority. This was amply demonstrated by Egypt, Honduras,
     Malaysia, Sri Lanka and Thailand which reduced their MMR by 50-85 per cent in periods ranging
     from 7 to 24 years.
   » India, recently equipped with the tried and tested MAPEDIR tool, is taking initiatives which if
     successful, could be replicated and contribute substantially towards making MDG5 of attaining
     75 per cent reduction in maternity deaths by 2015 a distinct reality.
   » Buttressing locally available data with insights culled from the MAPEDIR tool is an important
     method for achieving success in reducing maternity deaths.


Maternal mortality is a powerful pointer to the         An accurate understanding of the situation is called
outreach and quality of health services. Statistics     for. Most maternal deaths can be averted but in order
of maternal deaths, however, reveal only a partial      to do so, the right kind of information is needed to
story of why those deaths occurred and whether          understand the underlying factors that lead to the
they could have been prevented. Only a thorough         deaths. Only then can effective actions be taken.
examination of all the factors – social, cultural,      Each maternal death has a story to tell and can
biological and medical – that led to the maternal       suggest practical ways of addressing the problem.
deaths can present a comprehensive picture and a        Aggregating the findings from several deaths
reliable database to address the issues underlying      conveys a picture of the overall situation in a locality
this scourge.                                           or population group that can help communities to
                                                        determine lacunae and act on avoidable factors
The levels of maternal mortality vary greatly           that contributed to the deaths. MAPEDIR helps to
across countries due to variation in access to          communicate this vital information to all stakeholders
emergency obstetrical care, prenatal care, anaemia      such as administrators, health planners, medical
rates among women, education levels of women,           professionals, the community and women of
and many other factors. Investigations carried          reproductive age. It aims to build and influence
out in various studies in different countries           public policy for it to be translated into public health
suggest that women’s low status and lack                practices at all levels, including the health system,
of decision-making power are major factors              the community and the individual (see Box 2).
influencing maternal survival. Illiteracy and lack
of awareness also seriously affect timely access
to maternal healthcare.                                 MAPEDIR: A SEARCHLIGHT AND
                                                        A BEACON
women and their families are ill-informed about the
signs of complications and when and where to seek       MAPEDIR is an investigative tool which seeks to
care. As a result, they are unable to access care       kindle the community’s participation in probing why
when complications arise. Added to this, lack of        women died in pregnancy, delivery or soon after,
resources to afford the required care, absence of       with an emphasis on developing feasible solutions to
transportation to reach an appropriate care facility    the identified problems. The entire process includes
in time, inadequacy of medical services leading to      identifying and investigating maternal deaths,
delay, or faulty treatment on the whole, are major      sensitising the community, galvanising communities
contributors to maternal mortality. As things stand,    and health systems into action, and monitoring and
public health facilities are of deplorable quality in   adjusting interventions through continuing inquiries.
the poor, rural, remote, tribal or geographically
inaccessible areas. Often, lack of blood and vital      The MAPEDIR tool is a structured verbal autopsy
drugs; insufficient numbers of health personnel         questionnaire used to interview relatives and/or those
and hospital beds; mismatches in the distribution       who were close to the deceased woman. The findings
of health centres and service providers, and delay      can be aggregated, and, based on the inferences
in admitting or treating the patient all impair         drawn, corrective action taken at the block, district,
the pregnant woman’s health and chances of              state and national levels. Several countries including
survival. In some cases, serious errors of judgment     India have used the inquiry method to better
worsen the already grim maternal health and             understand the causes and complexities of tackling
survival scenario.                                      maternal mortality (see Box 3). Such inquiries

   Box 2: Evaluating the delaying factors contributing to maternal deaths

   wHO describes five main approaches to evaluate the delays: (1) community-based maternal death
   reviews conducted at the community level to ascertain common community factors that may have
   contributed to the maternal deaths, and to act upon the findings; (2) facility-based maternal death
   reviews conducted at the facilities by the providers as in-depth investigations of the causes of and
   circumstances surrounding maternal deaths with the primary objective of improving the quality of
   care; (3) confidential enquiries that constitute systematic multi-disciplinary anonymous investigations
   of maternal deaths within a region or country. These help to identify the numbers, causes and
   associated remedial factors; (4) surveys of near-misses or survivors of obstetric complications for
   ensuring improvements in maternal care; and, (5) clinical audit, a quality improvement process that
   seeks to improve patient care and outcomes through a systematic review of various aspects of
   the structure, processes and outcomes of care against explicit criteria and ensures the subsequent
   implementation of change.

   Different approaches have been used across the world, including India, to evaluate the delays in
   both community and facility settings. Experience in the use of these approaches has shown that
   successful implementation can take place at all levels. A commitment to act upon these findings
   is a key prerequisite for success.

   Box 3: Maternal and child death investigations undertaken by countries

   Maternal and child death inquiries have been conducted in many settings. Some examples include:
   (1) the routine practice of maternal death review by medical practitioners in the United Kingdom for
   more than 50 years; (2) hospital-based perinatal death reviews encouraged by the American College
   of Obstetricians and Gynaecologists in the United States; (3) community and hospital inquiry into all
   maternal deaths required by the Sri lanka Ministry of Health since 1985; (4) the community verbal
   autopsy and hospital-based confidential inquiry of maternal deaths encouraged by the Philippines
   Ministry of Health; and (5) maternal death reviews supported by wHO in selected hospitals of
   Bangladesh, Myanmar and Nepal. In India, the Tamil Nadu Reproductive and Child Health Programme
   has reviewed all maternal deaths and a sample of infant deaths since 2003, and the Government of
   Kerala has reviewed all maternal deaths since 2005. In addition, wHO has supported maternal death
   reviews at Safdarjung Hospital in Delhi and at Christian Medical College in Vellore.

bring maternal and child health issues to the             THE GOAL
limelight, besides supporting evidence-based
decision-making and advocacy by and with the              The sole purpose of MAPEDIR is to learn from
community – thus nurturing community participation        past tragedies and save lives in future without
and empowerment.                                          blaming anyone. Community-based maternal death

inquiry ascertains the personal, familial, social and     throughout India, to make these deaths more visible to
community factors that contributed to the maternal        the community and policy makers, and to provide the
deaths with a view to take positive action toward         much-needed evidence about the underlying causes of
improvement, and never to provide the basis for           these deaths in order to develop focused and effective
legal action, punishment or blame. A fundamental          interventions. MAPEDIR is part of the effort to ask the
principle of this approach is providing a confidential,   right questions to the right people.
non-threatening environment in which to describe
and analyse the factors leading to adverse maternal
outcomes. Ensuring confidentiality when sharing the       PHASED IMPLEMENTATION
findings of the death inquiries with and outside the
community leads to an openness in reporting which         The MAPEDIR tool, a structured verbal autopsy
provides a more complete picture of the precise           questionnaire, was suitably developed prior to its
sequence of events leading to the death.                  initiation in Purulia (west Bengal) in January 2005. It
                                                          was translated into Bengali and Hindi, adapted to suit
The collected data is aggregated, periodically            local conditions – factoring in cultural and linguistic
analysed and interpreted. The resultant findings help     specificities – and field-tested. (Subsequently,
define the problem, determine its scope, identify the     MAPEDIR was extended to four other states in a
biological and socioeconomic reasons contributing         similar manner).
to maternal deaths, and determine the interventions
crucial to address the problem and prevent future         On June 22, 2006, representatives from the
recurrence. whether at the micro or macro level,          Government of India, international development
MAPEDIR focuses on making maternal mortality a            partners, academics, NGOs, UNICEF and government
household, community and national health priority.        representatives from the five states implementing
Expected outcomes involve policy changes and              MAPEDIR (Jharkhand, Madhya Pradesh, Orissa,
stronger health systems.                                  Rajasthan and west Bengal) gathered in New Delhi to
                                                          review the process and its outcomes, share experiences,
                                                          learn from each other, and chalk out a roadmap for
MAPEDIR IN INDIA                                          the future. Following this, the MAPEDIR process was
                                                          initiated in each of the five implementing states with
Maternal death inquiry has been used in many              a workshop aimed at sensitising state and district
countries for many years as a way to identify medical     administrations. The project’s partner NGOs helped
and social factors contributing to maternal deaths.       mobilise communities, Panchayati Raj institutions,
The focus, however, has mostly been institutional.        village health communities, self-help groups, and village
The information gained from the inquiries has been        councils. A series of TOTs (Training of Trainers) and
used in various ways, e.g. to correct deficient medical   training sessions for interviewers were conducted in
practices, advocate for requisite improvements in         the MAPEDIR districts from January 2005 to February
healthcare and systems, raise community awareness,        2006. Interviewers were selected from among Auxiliary
etc. However, in developing countries, especially         Nurse Midwives (ANMs), ANM supervisors/lady Health
India, where millions of women still deliver at home      Visitors (lHVs), ICDS supervisors and NGO members.
and where a significant number of maternal deaths
take place outside the realm of health facilities, a      In each of the implementing states, MAPEDIR had
combined community/facility approach is vital. Better     to be localised. This meant not only translating
reporting of maternal and perinatal deaths is necessary   the verbal autopsy questionnaire into the local

language, but also tailoring the messages to fit the        of maternal deaths. The interviews revealed that the
local medium of communication. For example, in              immediate causes of maternal mortality most often are
Jharkhand, folk plays were and still continue to be         anaemia, eclampsia, haemorrhage, sepsis, obstructed
staged in village markets to sensitise communities          labour and unsafe abortion. Intermediate and underlying
about the need for birth preparedness.                      causes that emerged from the interviews were the
                                                            first and second delays in care-seeking, in turn caused
                                                            by the low social status of women, lack of awareness
   Objectives of MAPEDIR                                    and knowledge at the household level, inadequate
                                                            care-seeking and resources, and inadequate access to
   •	 Sensitising	communities	to	maternal	and	              quality healthcare (see Box 4 for case stories).
      perinatal health issues, including the need for
      birth preparedness and complication readiness;        As in many other projects, after initial resistance,
   •	 Inquiring	into	maternal	and	perinatal	deaths	         support for the MAPEDIR project has grown (see
      by identifying recent maternal deaths and             Box 5 for favourable impressions of some key public
      conducting community-based inquiries                  health officials).
      with close acquaintances of the women
      so	as	to	find	ways	by	which	future	deaths	
      might be prevented;                                   ROLE OF KEY PLAYERS
   •	 Sharing	the	findings	of	the	death	inquiries	
      with communities and helping them interpret           A maternal death is the outcome of a chain of events
      the data to develop appropriate interventions,        and disadvantages throughout a woman’s life. In
      as also advocate for improvements in                  populations with shockingly low female and overall
      healthcare	to	tackle	identified	problems;	and,        literacy rates, sensitising communities about basic
   •	 Using	the	findings	of	the	inquiries	to	               issues influencing maternal and child health becomes
      advocate with policy makers for necessary             a critical prerequisite before maternal death reviews
      improvements in healthcare systems.                   can be conducted. As previously noted, in most parts
                                                            of India, barriers to accessing maternal health services
                                                            include the absence of requisite knowledge and power
SCOPE                                                       to decide when to seek help; the unavailability of
                                                            means of transportation to a health centre; and the
The primary scope of MAPEDIR is to examine all              unaffordable cost of healthcare. The above factors
maternal and perinatal deaths (i.e. intrauterine            are magnified in the more traditional households
deaths from 24 weeks gestation) and each live birth         where adolescent girls and young married women
resulting in a neonatal death (up to 28 days of life).      have little power to influence decision-making within
However, currently, the scope has been expanded to          their families or vis-à-vis the wider world.
effectively examine all maternal deaths.
                                                            To raise awareness about these issues and heighten
                                                            the visibility of the causes precipitating maternal
OUTCOMES                                                    deaths is a collective responsibility. Fully aware of
                                                            this collaborative aspect, from the very beginning,
Interviews at the household level conducted under the       UNICEF has teamed up with other international
MAPEDIR project in selected districts in India identified   and national agencies, civil society networks and
the immediate, intermediate and underlying causes           their affiliates to create a supportive environment in

   Box 4: Relevance of MAPEDIR in India

   •	 A	25-year-old	woman	delivered	at	home;	developed	haemorrhage	soon	after	birth.	Family	members	
      sought the help of a local ‘practitioner’ (quack) who gave some injections and medicines. The woman
      was not taken to a hospital and died soon after at home.
   •	 A	30-year-old	woman	suffered	from	headache,	blurred	vision	and	swelling	of	feet	during	her	ninth	
      month of pregnancy. Her family sought the advice of a village quack who lived close by because there
      was no money to go to the hospital. The woman delivered twins at home and became semi-conscious.
      The	family	again	consulted	a	quack	and	the	woman	was	finally	referred	to	a	community	health	centre.	
      The CHC referred her to the district hospital but the woman died before transport could be arranged.
   •	 A	22-year-old	woman	delivered	at	home	with	the	help	of	an	untrained	dai. She developed post-partum
      haemorrhage and was taken to the CHC. Thereafter, she was taken to the home of the provider who
      was	treating	her	and	administered	IV	fluids.	Halfway	through	the	treatment,	the	drip	was	taken	off	and	
      the family was advised to take the woman home as she was ‘going to die’. The woman was taken
      home and died the next day.

which maternal death inquiries can be conducted.         (village-level institutions), women’s self-help groups,
Not surprisingly, at the core of MAPEDIR’s success       local NGOs, medical faculties of Indian universities,
and sustainability lies the involvement of the local     the Johns Hopkins Bloomberg School of Public Health
administration with the process. In districts where      (USA), and UNICEF. Communities are involved in the
the administration values the tool and has invested      investigative process through partnering with NGOs and
human and financial resources to make it work,           mobilising the Panchayati Raj Institutions, Village Health
results are encouraging. Conversely, where the local     Committees, Self Help Groups and Gram Sabhas.
administration is apathetic and the health system
weak, even though MAPEDIR enlists the support of         Good practices from countries that have reduced
NGOs, it is found that in the long run, responsible      maternal deaths show that strategic linkages
contribution from the district health authorities is     between individuals, communities and institutions
critical to scale up and sustain operations.             are critical to achieving targets. It is also widely


Partnerships expand possibilities. As in the broader
health and development fields where multi-pronged
strategies are being attempted, formal and informal
partnerships at various levels are critical to the
success of the MAPEDIR process. An exciting
collaborative effort, MAPEDIR is successfully
involving several institutions and groups with
different strengths: the Government of India, State
Governments, District Administrations, Panchayati Raj    A maternal death review in process/Patralekha Chatterjee, 2007

   Box 5: MAPEDIR, a blessing in disguise

   ”If we have a better idea of the grassroots factors causing maternal deaths, we can plan better, use our
   human resources better and use our funds better… If the causes can be pinpointed, MMR and IMR can be
   tackled. MAPEDIR is a tool which can help us use our manpower better, strengthen our health structures
   and implement our programmes better. It will help us pinpoint our shortcomings. without a system like
   MAPEDIR, our efforts to reduce maternal deaths will remain half-measures…”

   Dr Santosh Mishra
   Deputy Director (Nutrition) and Nodal Officer, Navajyoti Scheme, Orissa

   ”Unless we know the main reasons for maternal deaths, we cannot take effective measures to tackle
   them. It is critical to be able to pinpoint the delays causing loss of lives. The traditional system did not
   deal with these issues adequately – there were gaps in information. Now, using MAPEDIR, we can find
   out if the deaths are due to delays in decision-making at the household level, or due to lack of transport or
   at the facilities or if they are the cumulative outcome of all three…”

   Dr SP Yadav
   Director (RCH), Directorate of Medical and Health Services, Rajasthan

   “Initiating the MAPEDIR process has improved reporting of maternal deaths in Monthly Reports; the
   process of investigation is creating awareness among family members and other villagers; the BPHNs
   and ICDS supervisors are motivated and showing a lot of interest in carrying out the interviews; there is
   good cooperation from the household members of the deceased women; the sensitisation at the level of
   Gram Panchayats is creating awareness about maternal deaths and women Gram Panchayat members
   are also showing a lot of interest. The types of delays and the causes are coming out clearly from the

   Dr BB Patra
   Chief Medical Officer of Health (CMOH),
   Purulia at the State Consultation on Maternal Death Review at Kolkata, 25 September 2006

known that to reduce maternal and newborn                    single agency can cater to the entire spectrum.
mortality and morbidity, it is essential to build a          That is why globally, UNICEF’s MAPEDIR initiative
continuum of care that encompasses access to                 works with Governments, other members of the
skilled care during pregnancy, childbirth and the            UN family – UNFPA (Safe Motherhood) and wHO
post partum period. The care received at home                (Making Pregnancy Safer Initiative) and other
needs to be extended to care provided by a skilled           partners to ensure women’s right to reproductive
health professional at the primary care level,               health and survival. In India, MAPEDIR is an
followed by the care provided at the referral facility       integral part of the national effort to reduce
for women and newborns with complications. No                maternal deaths.

     » Women’s low status and illiteracy, along with lack of awareness, physical and financial resources
       and decision-making power, are the main impediments to women in developing countries like India
       accessing the required medical care for successful childbirth.
     » Absence of adequate health facilities further compounds the problem.
     » An accurate understanding of the situation with the help of the MAPEDIR tool facilitates stakeholders
       like administrators, health-planners, medical professionals and the community to devise effective
       strategies for averting maternal deaths.
     » MAPEDIR, suitably moulded to encompass local conditions and complexities, ensures confidentiality
       and forms a basis for positive action towards all-round improvement in the care received by a pregnant
     » Based on the aggregated findings of MAPEDIR, inferences can be drawn for corrective action at the
       block, district, state and national levels.
     » The crucial relevance of MAPEDIR in the Indian milieu and the response generated by its arrival in the
       country are amply demonstrated by the enthusiastic testimonies of government officials in different
     » The ultimate aim of reducing maternal deaths drastically can only be attained by a sustained
       collaborative effort involving individuals, communities, district administrations, village-level institutions,
       local NGOs, medical faculties of universities, State Governments, the Government of India, and
       international organisations like UNFPA, WHO and UNICEF.
     » Remedial measures at different levels are facilitated by MAPEDIR, which seeks to pinpoint the exact
       causes of maternal deaths and shares the data collected with various concerned agencies.

“MAPEDIR was conceptualised
to cover perinatal deaths as
well. But we decided to start
small and prioritise. In the
first stage, we decided to
cover maternal deaths.
Government and UNICEF
officers pre-tested the
questionnaires in the field,
modifying the length and
complexity along the way.
Investigation of perinatal
deaths may be introduced
at a later stage, when the
methodology stabilises and
is adopted institutionally by
state governments. Second,
MAPEDIR was originally a
scientific investigation tool
meant for research. It was
adapted to be transformed
into a tool for action, eliciting
community empowerment and
system responsiveness.”

Dr Marzio Babille
Chief of Health, UNICEF India


“When UNICEF decided to support maternal death            making to seek services? Are the required services
inquiry, they felt it would be useful to focus on         inaccessible because of distance, cost, or transport
community participation to maximise the use of            barriers? Answering such questions and taking
any interventions that were developed as well as          action is the most important aspect of MAPEDIR.
to increase awareness… This would also promote
commitment of the political and health systems… It
was vital to maintain confidentiality, from an ethical    THREE-HURDLE RACE AGAINST DEATH
standpoint to protect individuals (the questionnaire
respondents and families) as well as to promote the       MAPEDIR utilises a 3-Delays framework to identify
communities’ trust in our intentions… Developing a        the social, cultural, economic, medical and other
standardised approach would help implementation.”         factors responsible for maternal death. It helps the
Dr Henry Kalter, an international expert in verbal        health system to target interventions and prevent
autopsy instruments from Johns Hopkins Bloomberg          maternal mortality at every stage. In most instances,
School of Public Health, Baltimore, USA.                  women who die in childbirth are found to have
                                                          experienced at least one of the following three delays:
As mentioned, MAPEDIR is a verbal autopsy tool            •	 The First Delay is the delay in deciding to seek
that encourages community participation as well as           care for an obstetric complication. This may occur
strengthens the health system to better tackle the           for several reasons, including late recognition that
risk of maternal death. Maternal death inquiries are         there is a problem, fear of the hospital or of the
conducted in the community as an entry point to              costs that will be incurred there, or the lack of an
learn what went wrong and to understand issues of            available decision maker.
practices and care at the household level, maternal       •	 The Second Delay occurs after the decision
access to routine maternal and newborn healthcare,           to seek care has been taken. There is delay
transfer to and cost of referral services, provision of      in coordinating the method of transportation,
care at referral unit, and other key factors bearing on      resulting in a delay in reaching the care facility.
maternal survival.                                           Many villages have very limited transportation
                                                             options and poor roads linking the villages to
MAPEDIR is aimed at providing an understanding               maternal healthcare and referral facilities.
of the contributing factors that could and should         •	 The Third Delay is the delay in obtaining care at
be used by decision-makers and stakeholders to               the facility. This is one of the most tragic issues
address obstacles to quality obstetric care and to           affecting maternal survival. Often women have to
identify ways to prevent avoidable deaths. It seeks          wait many hours at the referral centre because of
to find out the pattern of obstetric and socio-              poor	staffing,	prepayment	policies,	or	difficulties	
demographic variables related to maternal deaths             in obtaining blood supplies, equipment or an
and aims to provide guidance on what needs to                operating theatre.
be done to prevent future deaths. MAPEDIR also
discovers and creates awareness of the underlying         The third delay is an area that many planners feel is
factors and barriers related to care-seeking              the easiest to correct. Once a woman has actually
for complications that lead to these deaths. It           reached an Emergency Obstetric Care facility, many
focuses on finding out exactly why mothers die.           economic and socio-cultural barriers have already
For example, is it because mothers are unaware            been overcome. Focusing on improving services in the
of the danger signs in pregnancy or unaware of            existing centres is a major component in promoting
the need to seek care? Or is it lack of decision-         access to quality emergency obstetric care.

METHODOLOGY                                                                         and sensitising them to maternal and perinatal
                                                                                    health issues.
MAPEDIR is organised at the block and district levels.                          •	 Identifying maternal and perinatal deaths through
In most states, a death notifier initially investigates                             local reports of ANMs, Anganwadi workers,
community reports of deaths of women of reproductive                                ASHAs and other community members.
age and transmits his/her findings to the block-level                           •	 Conducting the maternal death inquiries by
MAPEDIR team supervisor. S/he assesses each report                                  interviewing family members who are most
and assigns the suspected maternal deaths for a                                     knowledgeable of the circumstances of the illness
MAPEDIR interview. Interviewers in most states have                                 leading to the maternal or perinatal death.
chosen to work in teams of two, with one serving as                             •	 Analysing and interpreting the findings of the
the interviewer and the other as the data recorder.                                 inquiries.
The two interviewers and their supervisor comprise the                          •	 Sharing the findings with the community in such
block team. Some states include an additional, alternate                            a way as to promote the development of effective
interviewer and so have a four-person block team.                                   local interventions and advocacy by and with the
                                                                                    community for improved services.
A district official is expected to oversee project                              •	 Sharing of data with the administration for prompt
implementation in all the district’s blocks. Death                                  action and strengthening health systems.
reports and completed MAPEDIR interviews are
compiled and analysed at the district level with                                The flow chart on page 26 gives an idea of how the
technical assistance from UNICEF. Computer                                      MAPEDIR process unfolds.
software developed by a private company is
being used to facilitate data entry and analysis.
Subsequently, UNICEF shares the findings from                                   MAKING OF A MAPEDIR INTERVIEWER
the interviews with district and block officials.
NGO partners share the findings with communities                                Successful execution of MAPEDIR largely depends
in a way that facilitates their participation in the                            on the quality of training. Training for MAPEDIR
development of effective, evidence-based local                                  interviewers spans three days and is typically
health interventions. The ultimate goal of MAPEDIR                              facilitated by district dignitaries such as the Chief
is to reduce maternal deaths, through communities                               District Medical Officer (CDMO), the UNICEF district
themselves taking remedial measures to address                                  consultant/extender, and state-level resource
gaps at the local level, and officials taking corrective                        persons. Technical sessions on the first day usually
measures in the health system.                                                  include the following topics:
                                                                                •	 Introduction	to	MAPEDIR.
                                                                                •	 Introduction	to	the	state	of	maternal	mortality	in	
THE PROCESS                                                                         India, causes of maternal deaths, and the types of
                                                                                    delays that usually contributed to such deaths.
The community-based MAPEDIR process includes:                                   •	 Local	perceptions	and	practices	that	cause	
•	 Involving the community through grassroots                                       maternal deaths.
    structures i.e. Panchayati Raj Institutions (PRI) ,            9
                                                                                •	 Birth	preparedness	and	complication	readiness	–	
    village health committees and self-help groups                                  JSY and ASHA links.

9 PRIs are units of self-government proclaimed as vehicles of socioeconomic transformation in rural India, initially advocated by Mahatma Gandhi.
  Under a three-tier system of democratic decentralisation, Zilla Parishad is the apex body at the district level, followed by Panchayat Samitis at Block
  level as second-tier and Gram Panchayats, the third-tier at the village level.

MAPEDIR Implementation

•	 Introduction	to	verbal	autopsy	techniques,	
   including the importance of the consent form.          “I work in the area of public health and am familiar
                                                          with the basic medical issues. But the training
After the introductory sessions, participants are         in MAPEDIR taught me how to get information
taken through modules aimed at familiarising them         under difficult circumstances – ways to ‘introduce’
with the data collection instruments such as: (i)         myself when I step into a household where a
Existing structures of maternal death notification and    death has taken place. Earlier, one was a little
the desirable process, (ii) Maternal Death notification   hesitant. But the ‘role plays’ during the training
format, and (iii) All women’s Death Registration          session taught us simple techniques which can
Format. This is followed by reading through the           be used to allay the fears of a family where a
Maternal Death Inquiry (MDI) format (see Box 6) and       maternal death has taken place. I learnt how to
“practice sessions”. Participants break up into small     win the confidence of a grieving family. One can
groups and practice handling the data collection          win the confidence of a family by simply telling
instruments they had learnt about.                        them that even if they cannot undo the damage
                                                          done, they will be helping prevent further damage
On the second day, participants continue being            by participating in the interview...”
familiarised with the MDI format and get more
practice conducting maternal death inquiries              Tanuka Banerjee
through role-plays. On the final day, participants        Public Health Nurse, Joypur block PHC, Purulia
revise what they had learnt the previous day              District, who conducted several maternal death
and get more practice in administering the full           interviews until June 2007
questionnaire. The final session aims at sensitising

   Box 6: Format of the maternal death inquiry questionnaire

   The verbal autopsy questionnaire is divided into 10 sections which probe different aspects of the
   deceased woman’s life and circumstances leading to her death.

   These areas include: Information about the woman and her family i.e., years of schooling, occupation of
   husband, type of house of the family, access to electricity, whether belonging to BPl, caste and religion
   of the family, etc. The medical aspects on which information is sought include:
   •	 History	of	illnesses	before	the	pregnancy
   •	 Pregnancy	history
   •	 Details	of	antenatal	care
   •	 Details	of	the	events	and	obstetric	complications	that	possibly	led	to	death
   •	 Level	of	birth	preparedness	and	outcome	of	the	baby	(in	cases	of	death	during	or	after	delivery)
   •	 Care	seeking	and	barriers	to	care-seeking	for	obstetrical	complications	that	led	to	the	woman’s	death.

   Besides specific questions, there is also an “Open History” section which encourages respondents to
   describe in their own words “everything” that s/he knew about the illness/problem the woman suffered
   during her pregnancy, delivery or afterwards leading to her death and anything else which may be related.
   This captures valuable information which might otherwise have been missed during the interview.

   Inquiries about the maternal deaths that occur in a community are conducted over a period of several
   months in order to accurately identify common factors that can be acted upon to prevent further deaths.
   Ongoing inquiries carried out over several years allow a community to monitor the impact of its preventive
   actions and the need for additional interventions.

participants about the ethical issues surrounding          activity seems to have succeeded as seen from
the interview process and familiarising them               the response of a trained worker.
with the implementation plan of MAPEDIR in
various districts.
                                                           MAPEDIR GUIDELINES
The approach to and impact of training
(see Box 7) has a lasting influence on how the             How to Select the Best Respondent
trainees conduct the investigative tasks assigned          The respondent/s is the key to the quality of
to them and the reliability of the information they        information recorded about the deceased. S/he should
gather and are able to process. The sensitivity            be the one who was with the woman during her illness.
required of the interviewer as well as of the line         Usually, the woman’s husband, mother, sister, mother-
of questioning in a matter as tragic as death              in-law, or sister-in-law is the preferred respondent for a
makes it imperative that the investigator proceeds         maternal death. In some cases, more than one person
with utmost delicacy and respect for the bereaved          will have taken care of the woman or been present
family’s privacy as well as for the dignity of the         during different stages of the illness. For example, the
dead. In ensuring this, the MAPEDIR training               woman’s mother-in-law may have been present during

   Box 7: Training participants to use the inquiry questionnaire

   “I was convinced about the group-work approach in the training programme. On the first day, the
   participants expressed doubts about whether they would be able to deal with so many questions. On the
   face of it, their task appeared difficult, because the interviewers were expected to arrive at a family where
   a woman had died, ask many questions, and not offer any compensation. But actually on the second day
   of training, when they went through the formats, the participants realised that all the questions were not
   to be asked each time or in every case. For example, if the suspected cause of death was a particular
   one, then only that set of questions needed to be asked as was applicable to the cause. Through the
   process of elimination, the trainees soon learnt that all the questions were not relevant to each case.
   Therefore in an actual interview, s/he would use only one of the formats – not all, and not all questions.

   It was heartening to note that by the third day, participants in almost every training batch were convinced
   about their ability to deal with the questionnaire. The training took place at Bolangir for about eight
   months. It was completed in December 2006.”

   Dr Suresh Chandra Mishra
   Deputy Director, State Drug Management Unit, Government of Orissa, previously the Nodal officer for the
   Navajyoti scheme and closely associated with the MAPEDIR process

the birth at home, while the woman’s husband may            Confidentiality
have accompanied her to the hospital after the birth.       It is critical that all information obtained from
All respondents must be at least 18 years of age.           the MAPEDIR interviews remains strictly

The Ethical Dimension
MAPEDIR interviewers and supervisors are briefed                “women’s self-help groups (SHGs) can play
rigorously about the ethical aspects of conducting              a very important role in taking the process
research interviews such as informed consent and                forward. For example, in villages where
confidentiality. It is critical that all information            they are active, they can start little thrift
obtained from the MAPEDIR interviews remains                    societies with revolving funds. when a woman
strictly confidential.                                          requires instant cash to go to the hospital for
                                                                emergency care, she should be able to tap
Informed Consent                                                into the SHG’s emergency funds. Sometimes
All potential respondents have the right to determine           money is needed immediately. If communities
for themselves whether or not they will participate in          do not want to lose their mothers’ lives, they
the interview. Respondents must be 18 years old to              would have to work out mechanisms to deal
help ensure they are capable of making this decision.           with these details as well.”
Respondents must fully understand the purpose and
expected duration of the interview, the risks and               Dr Khynn Win Win Soe
benefits of being interviewed, and their right to not           Maternal Health Officer, UNICEF
answer any or all questions.

confidential. Maintaining confidentiality is an           Sharing MAPEDIR Data with the
ethical responsibility that is shared with all. It is     Community Groups
necessary to protect the respondents from any             Many parts of India where MAPEDIR is being
repercussions that might occur as a result of the         implemented have the advantage of community
information they have provided.                           structures such as self-help groups, which came into
                                                          existence more than two decades ago. Their primary
Falsification	of	Data                                     purpose was to make impoverished rural women
The whole purpose of the MAPEDIR project is to            economically self-reliant. However, today, these
collect, analyse, and share information with the          groups are engaged in many other areas affecting
community that can be used to prevent maternal            social development. Their leaders, often functioning
deaths. This will be possible only if the information     as catalysts and mobilising agents, are also updated
collected is authentic.                                   with MAPEDIR data.

   » MAPEDIR is a verbal autopsy tool that pinpoints the exact cause of maternal deaths, encourages
     community participation and strengthens the health system to better tackle the risk of maternal death.
   » The three delays in decision-making to seek medical intervention, arranging transportation, and getting
     adequate obstetric care at the right moment, are major hurdles to successful childbirth.
   » MAPEDIR is implemented at the block and district levels with the help of trained staff and technical
     support from UNICEF.
   » Prospective interviewers for MAPEDIR get a thorough grounding on the subject with special emphasis
     on maintaining decorum (vis-à-vis the delicacy of the situation), confidentiality and authenticity while
     conducting and recording interviews.
   » Different sections of the verbal autopsy questionnaire deal with the dead woman’s educational
     background, medical history and social, financial and environmental factors that could have
     contributed to her grave medical condition.
   » MAPEDIR data is shared with community groups, government officials as well as policy makers for
     necessary improvements in healthcare systems.
   » The ultimate goal of MAPEDIR is to reduce maternal deaths through communities themselves taking
     remedial measures to address gaps at the local level, and officials taking corrective measures in the
     health system.
   » A glowing example of MAPEDIR in Action and the benefits accruing is provided by the initiative in
     Purulia, West Bengal, one of the most underprivileged regions in the country.


Purulia district in west Bengal has become a                        regular process in Purulia from June 2005, the
laboratory for testing and shaping possible futures                 preparatory work started a year earlier. This entailed
in India, pointing the way forward for other socio-                 developing MAPEDIR as a tool and piloting the
economically underprivileged districts in the country.              instrument. The MAPEDIR process commenced
Despite its grinding poverty, the political will to                 with a workshop aimed at sensitising the state and
shape another image of the district is distinctly                   district administrations. NGO partners helped mobilise
present. The district administration, with support                  communities, Panchayati Raj institutions, village health
from UNICEF and other partners, is implementing                     communities, self-help groups and village councils.
strategies to boost neonatal and maternal survival
such as IMNCI (Integrated Management of Neonatal                    In January 2005, the MAPEDIR tool, a structured
and Childhood Illnesses) and MAPEDIR.                               verbal autopsy questionnaire was developed. The
                                                                    questionnaire was subsequently translated into
                                                                    Bengali, adapted to suit local conditions – factoring
MAPEDIR’S INITIATION IN PURULIA                                     in cultural and linguistic specificities – and field
                                                                    tested. A series of TOTs (Training of Trainers) and
Purulia was the first testing ground for MAPEDIR.                   training sessions for interviewers were conducted
Though maternal death inquiries started as a                        in the MAPEDIR districts. Interviewers were
                                                                    selected from among ANMs, ANM supervisors/
                                                                    lady Health Visitors (lHVs), ICDS supervisors,
                                                                    and NGO members.

                                                                    PHASED IMPLEMENTATION

                                                                    To ensure best results, MAPEDIR was launched in
                                                                    a phased manner. Purulia district consists of 20
                                                                    blocks. The 10 blocks located in the western part
                                                                    of the district are more disadvantaged than the rest,
                                                                    with female literacy rate below 30 per cent. These
                                                                    10 blocks (Arsha, Bagmundi, Balarampur, Barabazar,
                                                                    Bundwan, Jhalda I and II, Joypur, Manbazar I and II)
                                                                    were chosen for intense community and institutional
                                                                    mobilisation in the first phase.

                                                                    Actually, sensitisation is a gradual process that
                                                                    takes several meetings in remote villages with low
                                                                    levels of literacy and awareness. The entry point is
                                                                    often a video film about maternal health (made with
                                                                    support from UNICEF) that is screened at the village.
                                                                    The interactions with the rural communities begin
                                                                    with general discussions about safe motherhood
This map is offered for reference purposes only, and does not       and proceed to issues critical to maternal death
purport to represent the authentic boundaries of India as defined
by the Government of India.                                         (see Box 8).

A COLLABORATIVE VENTURE:                                    execution here consisted of a collaborative effort
AN INTERFACE WITH THE COMMUNITY                             of the Government of west Bengal, the Purulia
AND CIVIL SOCIETY                                           district health administration, the RG Kar Medical
                                                            College in Kolkata, local NGOs such as KAlYAN
Getting MAPEDIR off the ground in Purulia                   (involved in generating awareness about safe
demonstrates the value of partnerships between the          motherhood among communities), UNICEF health
Government and civil society networks to carry out          teams and field operatives, and the Johns Hopkins
a public health intervention. The MAPEDIR project’s         Bloomberg School of Public Health, USA, which

   Box 8: Connecting the unconnected

   Gurpana is one among the 125,000 villages in the country without electricity. A remote village in the
   tribal-dominated Bundwan block of Purulia, it is also without a telephone service. The block Primary
   Health Centre (PHC) is 30 km away. Six months ago, there was not even a tarred road linking Gurpana
   to any health facility. During an emergency, villagers would request the staff in the local police post for
   the use of their jeep. From time to time, sporadic bursts of extremist violence in surrounding areas shatter
   the calm of Gurpana. Steeped in acute poverty, amidst all its hardships and limitations, Purulia is poised
   to undergo a change that has significant potential to save maternal and child lives.

   A newly constructed warehouse in the village is doubling up as a community centre. On a hot, summer
   afternoon, pregnant women, young mothers carrying small children, grandmothers and a few fathers have
   gathered to watch a video film on maternal mortality on a battery-operated television. Many in the crowd
   cannot read or write but are mesmerised by the film, which talks about events that happen around them,
   places they have heard of, and situations they can identify with. The show is preceded and followed by a
   discussion initiated by field workers from KAlYAN, a local NGO partnering with the district administration
   and UNICEF. The focus here is to sensitise communities, that are often un-reached by the regular
   healthcare system, about safe motherhood and newborn care.

   “This is a village that has almost fallen off the map. Here, women do not know about new government
   schemes or the benefits they are entitled to… During our interactions, we stress the importance of
   institutional delivery,” says Sanjib Saha, UNICEF field operative in Purulia. “we make them aware of the
   warning signals for women who may be at high risk during pregnancy and delivery and the guidelines for
   referral transport to which they are entitled under the National Rural Health Mission.” Alongside, an NGO
   representative draws the attention of the crowd to the critical role of “three delays” in maternal deaths
   and the necessary measures to avert them.

   Gurpana is not an isolated instance. Today, such awareness drives are being conducted at mothers’
   meetings, community events, and other special occasions as part of the MAPEDIR process in 20 blocks
   in the district. “with greater awareness, we hope they would heed the danger signals and also work out
   community mechanisms to rush a woman in an obstetric emergency to the hospital,” adds Saha on a
   strong optimistic note.

gave technical support in developing the verbal       MAPEDIR’S FINDINGS AND
autopsy questionnaire.                                ACHIEVEMENTS

The Purulia district administration and UNICEF        At the time of printing the current report, the
teamed up with KAlYAN to disseminate key              second year of comprehensive data collection
messages among Gram Panchayat leaders and             using MAPEDIR was completed by Purulia district
members of women’s self-help groups. During           authorities (2007-2008)
these meetings, data on maternal deaths and the
MMR in the country and state were disseminated.       Up to early June 2007, 191 maternal deaths had
The interface with the community had to be            been reviewed. An analysis of the first 60 deaths
tackled differently. Booklets and cloth posters       has been shared with the community and district/
in the local language were used to instil             state health officials. The second set of data comes
awareness about danger signs during pregnancy         from a review of 102 maternal deaths that occurred
and childbirth.                                       in Purulia from July 2005 through June 2006. From
                                                      the review data it was noted that more deaths are
The sensitisation of the community led to some        reported in certain months of the year (see Table
unusual helpful initiatives. A typical example of     2). However, as the data pertains to only one year,
this comes from the Bundwan block. As there           it is difficult to infer any specific pattern or trend.
is hardly any local means of transport, and           Further, the maternal deaths reported from the less
ambulances cannot reach beyond a certain point,       developed blocks ranged between 1 to 10 deaths
one of the local Gram Pradhans (Village Heads)        during the period reviewed, thereby indicating that
took the lead to provide a local means of transport   notification of maternal deaths is directly related
– a van rickshaw – to a self-help group so that       to accessibility.
they could use it to connect to the nearest point
from where an ambulance can pick up the patient.      The maternal death reviews conducted under
The Block Development Officer of Bundwan was          MAPEDIR yielded valuable information on critical
very enthused by these developments and is            factors that influence a pregnant woman’s health
planning to put the telecom network in place to
bridge the gap further.                               Table 2: Maternal Deaths by Month
                                                      Month                              Number of Deaths
The community-based social audit of maternal          July 2005                                          15
deaths in Purulia revealed that rural medical         August                                             15
practitioners (RMPs) play a critical role during      September                                            7
pregnancies and home deliveries in villages. To       October                                            10
exclude them from a public health intervention        November                                           11
could be counterproductive. Accordingly concerted     December                                             4
efforts were made to engage them, invite them         January 2006                                         6
to workshops, inform them about key issues in         February                                             3
maternal health, and update their knowledge about     March                                                6
why, when and where maternal deaths were taking       April                                                6
place. Such orientations were held for RMPs in all    May                                                10
20 blocks in Purulia with the aim of changing their   June                                                 9
often incorrect practices.                            Total                                             102

and survival. Several of the instructive findings       the fact that many sought care too late, increasing
are highlighted.                                        the severity of illness and chances of dying on
                                                        reaching a facility. About 23 per cent (n=24)
                                                        occurred at home, while the rest 16 per cent
FINDINGS OF MAPEDIR                                     (n=16) occurred either en-route from home to a
                                                        health facility or from one facility to another (from
1. Timing of Maternal Deaths                            first to second facility and from second to third
The MAPEDIR data reveals that most of the               facility (see Figure 2).
maternal deaths (67 per cent) occurred during
labour or delivery out of which 13.4 per cent           4. Pathway Analysis
occurred before delivery and during labour, 13.4 per    Of the 102 maternal deaths, 17 women died at
cent before delivery of placenta, 27 per cent within    home – either not making any attempt to seek
less than 24 hours delivery, and 46 per cent within     formal care or, even if they decided to seek care,
or more than 24 hours after delivery. About 21 per      they died before leaving home. Among the 85
cent women died during pregnancy. A total of 13         mothers who left home to seek care, 75 reached
deaths occurred during / after abortion of which        the first facility and 10 died on the way. Of the
five were found to be spontaneous and seven were        75 who reached the first facility, 32 died at that
induced (see Figure 1).                                 facility and remaining 43 were referred to the next
                                                        level. From the latter group, 5 returned and died at
2. Neonatal Deaths                                      home. Of the 38 mothers who set out to access
Among 68 women who died during labour and               the second referral facility, 4 died en route,
delivery, 13 per cent (n=9) experienced intrauterine    27 died at the second facility, and 7 were referred
foetal death (IUFD); 16 per cent (n=11) children        to the next facility. Of those 7, 2 died on the way
were stillborn; 22 per cent (n=15) were born alive      to the third facility, 2 returned home and died,
and died; and 48.5 per cent (n=33) were still alive     and 3 who reached the third facility died there
at the time of the interview. Evidence indicates that   (see Figure 3).
the care during and after delivery remains the most
crucial time for both maternal and neonatal survival.   5. Causes of Death
                                                        Fifty three per cent of maternal deaths were due to
3. Place of Death                                       direct obstetric causes, 13 per cent from abortion,
About 62 per cent (n=62) of the maternal deaths         17 per cent haemorrhage, 19 per cent eclampsia,
occurred at health facilities. This could be due to     and 4 per cent other diseases. 21 per cent were

Figure 1                                                Figure 2

           due to indirect causes, with severe anaemia
           accounting for nearly half of these deaths. The
           verbal autopsy interview could not determine the
           biological diagnosis in 26 per cent of the deaths
           (see Figure 4).

           6.	Demographic	Profile	of	the	Deceased
           At the time of death, the age of the mothers
           ranged from 15 to 35 years, with the majority
           dying at 24 years. Early marriage and early
           child-bearing below the age of 18, when most
           obstetric complications tend to occur, may have
           been major contributors to these deaths. The
           age at marriage ranged from 11 to 24 years
           but most of the women who died were
           17 years old at the time of marriage. More than
           a third (35 per cent) of women died at their first
           pregnancy, 53 per cent were between second
           and fourth pregnancies, and the remaining
           12 per cent were at the fifth pregnancy or more.
           These statistics confirm that early marriage, too
           many pregnancies, and too close birth intervals
           pose major risks to the survival of pregnant
           women, and account for a large proportion
           of maternal deaths.

           7.	Socioeconomic	Profile	of	the	Deceased
           Predictably, most of the deaths occurred in the
           poor families with minimal facilities. 81.4 per cent
           (n=83) women lived in kutcha houses, 99 per cent
           (n=100) did not have their own toilet, and 87.3 per

Figure 3   Figure 4

cent (n=89) did not have any electricity.
The data further revealed 61 per cent (n=61)              Box 9: Decision-making for care seeking
of the mothers who died were from the lower caste,
37 per cent (n=37) from the scheduled caste (SC),         Husbands played the major role in deciding
and 24 per cent (n=24) from the scheduled tribes          to seek care:
(ST). About 41 per cent (n=39) families of the            First Facility
deceased women held a below poverty line (BPl)            35 per cent, n=68/196 decision-makers
card, but sadly, 34 per cent (n=35) were not aware        Second Facility
of the benefits of a BPl card. A majority of the          33 per cent, n=28/84 decision-makers
deceased women were illiterate, with the duration
of their schooling ranging from 0 to 10 years. In         The women themselves had little role in
case of their husbands, a majority had four years         this decision:
of schooling, while the rest had schooling ranging         First Facility
from 0 to 10 years.                                        6 per cent, n=11/196 decision-makers
                                                          Second Facility
8. Decision-making Power and Reasons                       4 per cent, n=3/84 decision-makers
for Seeking Care
The role of the deceased women in seeking care            For choosing the first health facility:
was inconspicuous. Cumulatively, in a majority of         Most common factor=proximity
cases (35 per cent for first facility and 33 per cent     Second common determinant=quality of care
for second facility), the deceased’s husband played
the key role in deciding to seek care. The woman          For choosing the second health facility:
had little or no role in the decision-making process.     Most common factor=referral to the facility
The most common factor in choosing a health
facility for seeking care was its proximity either
from their home to the facility or from one facility    women decided earlier, formal care-seeking
to another. The quality of care expected was            increased. The woman was one of the decision
the next determinant in seeking care. Generally,        makers only 9 per cent of the time in seeking
once a complication endangering the health and          formal care first, and less than 2 per cent of the
survival of the pregnant woman arose, the husband       time when she never did seek formal care first.
played a major role in deciding when and from           For the first action decision makers, the woman’s
where to seek care. This appropriation of decision-     husband was the most frequent individual
making authority by the male is attributable to         decision maker. Very rarely was the woman herself
socioeconomic and cultural factors prevalent in         one of the decision makers for going from the
rural India, limiting women’s choices and decision-     first to the second facility. This may be due to the
making powers (see Box 9).                              woman’s serious condition decreasing her ability to
                                                        make decisions.
9. Decision-maker for Seeking Formal Care
For seeking formal care, the husband and ‘others’       10. Mode of Referral Transport
accounted for 95 per cent cases (see Table 3).          The most commonly used transport for reaching all
                                                        facilities was a taxi. This was used by 47 women
Although the woman herself was rarely a decision-       for travelling from the home to the facility, by 18
maker, disaggregated data suggests that when            from first to the second facility, and by 2 from

 Table 3. Who decides to seek formal care?
 Decision                 Woman never      Woman sought formal               Woman sought                Total (of all
 maker*               sought formal care      care, but not first           formal care first    decision makers for
                               (17/102)                (38/102)                    (47/102)             102 women)
                         n           %            n           %                 n         %           n             %
 Self                    0            0           1            2            10             9         11              6
 Husband                 8           33          27           41            33           31          68             35
 Others                 16           67          37           57            64           60         117             60
 Total                  24         100           65         100           107           100         196            100

*Multiple responses

second to the third facility. Ambulance services              in 29 per cent of deaths, the families did not
were used by only 30 of the deceased mothers.                 consider that the woman was sick enough. In
Of them, 7 used ambulance to move from home to                13 per cent of cases, the family thought that
the facility, 21 from first to the second facility, and       non-formal or traditional care was needed to
2 from second to the third facility. Eleven mothers           treat the problem, and about 6 per cent did
were found to have been transferred to the facility           not have any faith in formal care. Other
from home by rickshaw or by cart, three by bus,               reasons were non availability of transport
and incredibly one woman even walked to seek care             (19 per cent), and financial constraints in paying
for the complication to which she later succumbed.            for the transportation and healthcare costs
                                                              (23 per cent). About 6 per cent of mothers were
In any medical emergency, having to rely on slow              not able to go to a facility to seek care as they
moving transportation even across small distances             did not have anyone available to accompany
can be costly to human life. Improved mobility                them to the facility (see Table 4).
can make a major difference to timely access to
critical care. Strategies to overcome the mobility            Clearly, perception of the severity of illness and
barriers need to be based on local conditions.                the choice of appropriate care-providers were the
Families, especially husbands, generally have the             most common care-seeking constraints for women
primary responsibility for deciding on the mode               who never sought formal care, while cost of care
of transportation. Attempts should be made by                 and transportation issues were more important
the NGOs to sensitise husbands and other family               considerations for women who sought formal care
members on the criticality of timely care-seeking as          first or later.
well as to mobilise communities for sensitising local
operators and vehicle owners to help women with               Very often, women and their families do not
obstetric complications. Communities or local self            recognise the life-threatening signs of pregnancy-
governments could establish a fund to reimburse               related complications as well as the seriousness
individual drivers and vehicle owners for fuel when           of the condition, do not have faith that they can
they transport obstetric emergencies.                         be managed through formal healthcare, and may
                                                              not be able to arrange transport due to lack of
11. Reasons for not Seeking Formal Care                       money – resulting in delay in deciding to seek
Of the 55 families which delayed seeking or did               care at the right time. Overall, cultural, economic
not seek formal care causing the woman to die,                as well as infrastructural factors influence how

 Table 4: Problems related to seeking care and reasons thereof
                                                           Never sought        Sought formal         Sought formal
 Care-seeking problems
                                                            formal care      care but not first*       care first*
                                                          n    %              n     %               n     %
                      Not sick enough                      8    53            7     19              3     21
 and cultural         Needed traditional care              2    13    67      5     14      38      0      0      29
                      Too sick to travel                   0     0            2       5             1      7

 Cost and             Cost (transport, care, etc.)         2    13           10     27              5     36
                                                                      33                    46                   57
 transport            Transport not available              3    20            7     19              3     21

 Other                No one to accompany her              0     0            3       8             2     14
                                                                       0                    16                   14
 reasons              Not satisfied with available care   0      0            3       8             0      0
 Number of reasons given                                  15         100     37           100      14            100
 Number of women                                          13                 21                     7
*First action taken

fast and if at all a woman’s illness will evoke                 facilities, at all levels, the cost of care would be
formal care. Consequently, educational campaigns                a major inhibitor to seeking care. The frustrating
need to focus on all these issues. Further,                     feeling that even after the expense undertaken,
extensive discussion with community members                     lives were not saved would be a strong factor
may be necessary to determine what action is                    dissuading many from seeking future care.
acceptable and feasible to promote in the
context of the community and the structure of                   Considering the poor socioeconomic status of the
health service.                                                 families where a majority of maternal deaths occur,
                                                                strengthening the implementation and coverage
12. Time and Cost Aspects                                       of different poverty alleviating programmes
As seen in Table 5, the time taken to decide to                 becomes imperative to making healthcare and
seek care and arrange for transport from home                   access more affordable.
to the facility was around 4-5 hours for most
mothers. Yet, any woman having post partum                      13. Need for Obstetric Emergency
haemorrhage would survive only for a maximum                    Care Preparedness
of two hours. At the referral level, in both first              when poor rural families decide to seek care at
and second referral facilities, most cases were                 a formal healthcare facility, they often go to the
attended within 5 minutes of arrival. The cost of               nearest Block PHC or Health Centre (BPHC/HC)
care provided at the second facility was higher                 where emergency obstetric care is not available.
compared to that incurred at the first facility.                From there they are then referred to another
Most of the families spent around Rs 500                        health facility. This increases the distance, cost,
(Rs 41= 1 USD) at the first facility and almost                 as well as time – all of which are very precious
all the families spent more than Rs 1,400 at the                to save a pregnant woman’s life. Therefore, it is
second facility, some considerably more than                    essential that pregnant women and their families
others. while the cost difference is most probably              as well as various tiers of the health service
due to the varying care provided at different                   infrastructure – from the apex to the

Table 5: Time and cost for all women who sought formal care (n=85)
                                                                     Median               Range
Distance travelled from home to 1 facility
                                                                     27 km                1-197 km
Time of travel from home to 1st facility                             1 hour               0-5.8 hours
Cost of transportation                                               Rs 450               Rs 0-4,600
Cost of care                                                         Rs 800               Rs 0-28,000
Seen by doctor or nurse, within                                      5 minutes            0-7 hours
For 43 women who left the 1st/2nd facility alive, time at facility   24.5 hours           0-168 hours (7 days)

           Time and cost of seeking care for women who reached 1st facility (n=75)
                                                                     Median               Range
Time taken to decide to seek care                                    4 hours              0-9 days
Time taken to arrange transport                                      1 hour               0-12 hours
Distance travelled from home to 1st facility                         12 km                0-60 km
Time of travel from home to 1st facility                             30 minutes           0- 4.2 hours
Cost of transportation                                               Rs 300               Rs 0-1,100
Cost of care                                                         Rs 500               Rs 0-6,000
Seen by doctor or nurse, within                                      5 minutes            0-60 minutes
For 43 women who left the 1 facility alive, time at facility
                                                                     24 hours             0-196 hours (8.2 days)

           Time and cost of seeking care for women who reached 2nd facility (n=34)
                                                                     Median               Range
Distance travelled from 1st to 2nd facility                          32 km                11-100 km
Time of travel 1 to 2 facility
                 st    nd
                                                                     1 hour               0-3.5 hours
Cost of transportation                                               Rs 400               Rs 0-1,500
Cost of care                                                         Rs 1,400             Rs 0-25,000
Seen by doctor or nurse, within                                      5 minutes            0-7 hours
For 7 women who left the 2 facility alive, time at facility
                                                                     12 hours             2-72 hours (3 days)

peripheral – be prepared for and educated to                 ACHIEVEMENTS OF MAPEDIR
tackle birthing-related emergencies that can occur
at any time. Being prepared for a safe delivery and          Beyond fact-finding that has yielded a wealth of
ready for an obstetric emergency will reduce these           information bearing on future actions to prevent
life-threatening delays and save the lives of both           maternal mortality, the MAPEDIR experiment in
mother and baby.                                             Purulia has several achievements to its credit:

                                                         concerning maternal health to mothers’ groups,
   Key findings from MAPEDIR data:                       even health workers, without using any jargon
   •	 Most	maternal	deaths	take	place	in	the	            or technical phrases,” says Mehrunnisa,
       post-partum period with majority taking           KAlYAN’s block supervisor for Jhalda I and II
       place on the first post-partum day.               blocks in Purulia district.
   •	 Bleeding	is	the	most	common	cause	of	
       death followed by eclampsia.                      Over the past two years, KAlYAN’s field workers
   •	 Most	women	who	died	belonged	to	                   have been speaking about MAPEDIR in village
       Scheduled Caste/Tribe and were illiterate.        level gatherings, explaining the significance of
   •	 Family	members	of	most	women	                      the findings and alerting mothers and community
       who died were not aware of Below                  workers about the ‘danger signs’ based on
       Poverty line (BPl) entitlement regarding          insights from MAPEDIR reviews. Typically, homely
       medical care.                                     analogies are used to illustrate a key concern.
   •	 Women	have	very	little	role	in	deciding	           At mothers’ meetings where a significant number
       to seek healthcare.                               among the audience are illiterate and were married
                                                         off very early, Mehrunissa uses the analogy of
                                                         a ‘half-baked clay pot’. Such a pot can break
1. Demystifying Maternal Health                          easily. Similarly, if a woman conceives at a very
The main merit of MAPEDIR is that it seeks to            early age, she is exposing herself to risk during
demystify maternal health and bring the household        pregnancy. Although this may sound like common
and community closer to the healthcare system.           sense, much of the information imparted by
In that way, it is much more than an investigative       outreach workers like Mehrunnisa is a revelation
tool or a fact-finding process. Although at the          to the women in the audience.
start of MAPEDIR, considerable effort went into
developing the questionnaire – field-tested for the      Because participation in such meetings is
first time in Purulia – the emphasis should not be       empowering both for the healthcare giver
on the questionnaire per se. As Dr Henry Kalter of       and seeker, in itself it becomes a healthcare
Johns Hopkins points out, “The questionnaire is a
tool to facilitate a process. MAPEDIR is a process
of raising awareness: getting people concerned
and involved with maternal and child health issues,
as well as more knowledgeable and empowered
to do something about it... It is intended to help
people overcome the powerlessness that comes
from the feeling that you cannot do anything to
change outcomes…”

Others involved in the project echo the above
perception. Frontline workers stress that working
towards safe motherhood is a gradual process in
a district like Purulia. “First, one has to create the
conditions in which maternal death reviews can           Mehrunnisa, KALYAN’s block supervisor for Jhalda I and
                                                         II blocks in Purulia district, teaching village women how to
be carried out. This means explaining basic issues       recognise danger signs in pregnancy/Patralekha Chatterjee, 2007

intervention. Experience of such reviews with         between pregnant women in remote villages in
the community has shown a major impact on those       Purulia and their access to quality healthcare.
involved. Often, those participating in the reviews   Happily, an innovative community-led transport
are motivated to change their behaviour, practices    system for obstetric emergencies has emerged
or service delivery methods. Tracing a deceased       as a legacy of the MAPEDIR process.
mother’s path through the community and
healthcare system, and describing the actions that    In an analysis of the first 60 maternal death
might have prevented her death, have a meaningful     interviews that was shared with the community,
personal effect.                                      relatives of 19 per cent of the women who delayed
                                                      or never sought formal healthcare, cited non-
2. Native Ambulance, a Ripple Effect                  availability of transport as a serious obstacle; while
The first tentative steps towards a sustainable,      another 29 per cent mentioned lack of money
community-based transport system for obstetric        for transport. These findings acted as a wake-up
emergencies have been taken in one of the most        call, alerting community leaders, families and local
backward regions in India – thanks to MAPEDIR!        officials to the causes and circumstances leading to
                                                      the deaths of women whose lives could have been
Rugged terrain, unpaved roads, lack of transport      saved if elementary precautions and measures had
and communication are some of the key barriers        been taken. The situations were familiar but prior to
                                                      the launch of MAPEDIR, not much thought had been
                                                      given to tracing the linkage between deaths and the
   “we always thought ‘development’ meant             delays causing them.
   building roads. But it does not end there.
   Now we realise that it also means making           Over the past two years, against the backdrop of
   sure there is transport and that people            new government schemes offering incentives for
   have access to healthcare and education.           institutional deliveries, MAPEDIR data was shared
   On the last Saturday of every month, each          with communities at village meetings, gatherings
   panchayat or village council holds a meeting       of gram panchayat members and women’s
   to discuss health-related issues. Since last       groups etc. Several gram pradhans in Purulia
   year, these meetings have devoted a lot of         were prompted to come up with mechanisms to
   time to maternal and child deaths. These           address one of the weakest links in the chain of
   interactions have made me realise that a key       circumstances causing a maternal death: lack of
   issue in saving mothers is getting them safely     transport to take a pregnant woman to the nearest
   to a health centre or hospital for delivery.       appropriate health facility.
   If we can achieve this, we can prevent
   many maternal deaths. As I talked about            Shankar Prasad Singh, a village school teacher
   this with others, the idea of a van                and gram pradhan of Dhadka gram panchayat
   rickshaw emerged…”                                 in Bundwan block in Purulia, was perhaps the
                                                      first village-level leader in the area to realise the
   Shankar Prasad Singh                               ‘political’ value of organising local transport for
   High school teacher and Gram Pradhan               pregnant women in his constituency. Singh was
   of Dhadka village council, Bundwan block,          quick to translate the idea into action. “I realised
   Purulia                                            I could tap into the untied funds available to the
                                                      gram panchayat (village council) to buy these

rickshaws. I got two such van rickshaws at a cost        3. Stimulating State Action
of a little over Rs 12,000. They were made by local      MAPEDIR has spurred not only communities,
people…,” he adds.                                       but also state and district levels of the
                                                         government to concrete action. Following the
Similar efforts are underway in other villages,          launch of MAPEDIR, the Government of west
with communities evincing a new resolve among            Bengal has passed an order to review every
them to tackle the barriers to timely care for           maternal death, toning up the entire maternal
pregnant women at risk. Earlier this year, a locally     death reporting system. Along with community-
manufactured van rickshaw was placed with one            based reviews, facility-based reviews of maternal
of the self-help groups in Badakhula, a remote           deaths have also been initiated, to address the
village, so that pregnant mothers could use it to        third level of delay (calling for prompt attention
reach a health facility for delivery. Badakhula is       and improvement of the quality of care to
located in forested area. The approach road to           pregnant women at health facilities).
the village is a mud track; the nearest health
sub-centre is 5 km away. There is no phone               4. Strengthening the System
in the village. A bicycle is the common mode             MAPEDIR has speeded up ongoing efforts to
of transport.                                            improve the health infrastructure. For example,
                                                         all maternity beds in public sector facilities in
Pregnant women were carried in a duliya, a string        west Bengal have been made ‘free’ for all;
cot, till the nearest point from where a jeep could      the GOwB is working on a cashless
be hired to take them to the Bundwan block PHC.          (voucher-based) referral transport system
In extreme circumstances, they even walked.              (in addition to the community initiatives that
A new community level transport for obstetric            have already been put in place by various
emergencies – the van rickshaw – is now expected         gram pradhans). The MAPEDIR process has
to step up institutional deliveries, encouraged by the   made health service providers more aware of
government’s Janani Suraksha Yojana.                     systemic gaps.

This has had a ripple effect. In June 2007, the
Gram Pradhan of Kumari Gram Panchayat of                 FORWARD MARCH
Manbazar II block in Purulia handed over two van
rickshaws to two local self-help groups in the           The next steps in Purulia include spurring
least developed villages where there are almost          village leaders to establish a local emergency
no transport facilities and about 75 per cent of         transport system to initially link up the 10 least
deliveries take place at home.                           developed blocks in Purulia. The remaining
                                                         10 blocks will also be targeted for similar
An operational guideline has been prepared and           interventions. Perinatal death reviews and facility-
the communities have decided that the van                based reviews of maternal deaths are also on
rickshaws will go directly to the health facility as     the cards. KAlYAN, the NGO partner that has
no mode of communication is available in these           been working in the district since 2005, has
villages. These van rickshaws, which will be used        formulated an action plan for intensifying efforts
for transport of non-obstetric emergencies as well,      for generating community awareness on safe
are also being linked to the local microfinance          motherhood and newborn care in all blocks of
system through the SHGs.                                 Purulia district in the near future.

Challenges Ahead                                             The socio-cultural context is another
The key challenge in Purulia is effective and regular        challenge. In villages steeped in superstition
supervision of the process. Many block medical               and illiteracy, where quacks and traditional
officers who are entrusted with supervisory                  birth attendants still configure the local
responsibilities still think routine rather than results.    practices and services, considerable additional
In practice, this leads to neglect and oversight             effort is required to change the people’s
when a filled questionnaire is signed off, without a         mindsets. For instance, many families still
thorough scrutiny. Feedback from the field suggests          follow the popular practice that a woman should
that in some instances, the questionnaire was                not eat much when she is approaching her
perceived as lengthy, and was submitted incomplete.          expected date of delivery.

     » In June 2005, Purulia in West Bengal, one of the most disadvantaged and underprivileged districts in
       the country, was selected to become the testing ground of MAPEDIR in India.
     » Preparatory work, started a year earlier, included sensitising and mobilising communities, Panchayati
       Raj institutions, village health communities, self-help groups and village councils, as also the state and
       district administrations.
     » MAPEDIR’s structured verbal autopsy tool was suitably moulded to encompass local conditions and
       field-tested in 10 of the more disadvantaged blocks having no roads, electricity or telecommunication,
       and a female literacy rate below 30 per cent.
     » A true-to-life video film featuring local situations concerning maternal deaths, supported by awareness
       generating booklets and posters in the local language, served as an inspiration to all-round concerted
     » The example of a village Pradhan providing locally built van rickshaws for transporting obstetric
       emergencies was emulated by others – and even a Government official promised to work towards
       providing a telecom network.
     » The success of the MAPEDIR mission in Purulia was the result of a collaborative effort of GOWB, the
       district health administration, RG Kar Medical College in Kolkata, local NGOs, UNICEF health teams
       and field operatives, and the Johns Hopkins Bloomberg School of Public Health, USA.
     » MAPEDIR’s detailed findings on the causes of maternal deaths, demographic and socioeconomic
       profile of the deceased, their reasons for accessing or not accessing healthcare in time, etc., provided
       a repository of analytical data for immediate and future action at different levels.
     » The achievements of MAPEDIR at Purulia included demystifying maternal health to the local
       population, stimulating the community and State into sustained action, and strengthening the
       healthcare system as a whole.
     » The Purulia experiment of MAPEDIR has yielded a wealth of experience and information that will have
       a strong bearing on future strategies and actions to prevent maternal mortality in India.
     » Inside stories of women from Madhya Pradesh, Orissa, and Rajasthan, though with a different
       geographical backdrop, essentially reflect the same helplessness and despair that go hand in hand with
       poverty, illiteracy and a non-supportive and exploitative environment.

“You can tell the condition
of a Nation by looking at the
status of its women.”

Jawahar lal Nehru
India’s	first	Prime	Minister

              MAPEDIR IN ACTION

A. GUNA AND SHIVPURI, MADHYA PRADESH                           the poignancy of a maternal death in a remote,
                                                               rural corner of India. It also holds lessons for
The snapshot from Muradpur village in Guna                     policy makers and practitioners grappling with the
district, Madhya Pradesh in Box 10 below captures              challenge of averting such tragedies in this vast,

   Box 10: Behind the veil

   It is a journey down bumpy roads, through dusty, parched land dotted with mud huts and thatched roofs. All
   around are shades of brown. The only visual relief is from the vivid scarlet of the Flame-of-the-Forest tree. The
   landscape surrounding Muradpur village in Bamori block (Guna district) is reminiscent of so many arid patches
   across India where livelihoods are tenuous and where women are at high risk during pregnancy and childbirth.

   In Muradpur, the arrival of the MAPEDIR interviewer is an event, breaking the culture of silence that engulfs
   the vast majority of women. Family members are surprised that anyone cares enough to ask so many
   questions about the deceased. Here, most women live behind the veil, unaware of and scarcely touched by
   the world outside the four walls of their homes. A health sub-centre almost at their doorstep does not translate
   into healthcare for them.

   Tracking a maternal death in such a context is vital because it tells the untold stories of women whose lives
   and deaths go unheeded. The inquiry remains confidential. The name of the woman is not divulged, nor blame
   apportioned. At the end, many questions still remain unanswered. But the interview brings out unknown
   aspects of the dead woman’s life that traditionally would have found no place in official records.

   A recent maternal death review in Muradpur traced the chain of events leading to the death of a woman who
   was seven months pregnant with her third child. The woman, in her twenties, had died in the district hospital,
   leaving behind two small children. A possible cause: eclampsia. without validation from concerned medical
   authorities or medical records, it is difficult to specify the exact cause of death; but in this case, where and
   how the woman had lived tells us a great deal. The family subsisted on dairy farming. They were above the
   official poverty line but lived in a mud house. None in the family had gone to school; the women covered their
   faces behind a veil. A health centre was within walking distance, but the dead woman had never gone there.
   None in the family could recall whether she had ANC check-ups or how many. No one knew if she suffered
   from any illness and no one was aware of danger signs during pregnancy.

   One early morning, at 6 am, the woman had complained of an acute back pain, her sister-in-law told the
   female health worker conducting the interview. The village ‘dai’ (untrained midwife) was summoned and the
   suffering woman was given some pills. Subsequently she was taken to a local practitioner (quack) as there
   were no medical personnel in the sub-centre at that hour. when things did not improve, the family elders
   had taken the decision to take the woman to the district hospital. Her husband, a farmer, had left for work.
   His brother and sister-in-law escorted the ailing woman to the district hospital. She had a seizure on the way
   to the hospital, was put on saline on arrival, and started vomiting blood after some hours, the sister-in-law
   recalled. The woman expired the next morning.

sprawling state with one of the lowest ratings in        reported and those suspected of being maternal
human development in the country. In Madhya              deaths are investigated. During the training,
Pradesh, 37 per cent of the population lives below       interviewers are advised not to visit a family
the poverty line – significantly higher than the         during the official mourning period. Therefore,
national average of 26 per cent. Poverty co-exists       interviewers typically visit the family three to five
amid vast pools of illiteracy, in a socio-cultural       weeks after the maternal death has taken place. In
milieu where women are accorded low status,              most instances, it has been found that the family
under-age marriages continue, and the paucity of         is comfortable talking about the death and does
health services and trained medical personnel add to     not mind being interviewed. However, in some
the risk of child bearing. Poor road connectivity in a   cases, repeated visits have to be made to meet
geographically large state accentuates the difficulty    all the respondents.
in accessing healthcare.
                                                         Encouraging Results
All these factors make for a lethal mix which results    The MAPEDIR process has led to the initiation of
in among the worst maternal and infant mortality         health audits in all Gram Panchayats (village councils)
ratios in the country. But all is not bleak. There is    in Guna since January 2007. Such audits review five
a growing realisation within the state and district      main issues i.e., maternal deaths, ANC registration
administrations that things must change. MAPEDIR         and checkups, immunisation coverage, institutional
is creating the evidence base to speed up                deliveries, and cataract detection and operations in
interventions that would strengthen the health           the panchayat limits. Other significant outcomes
system and empower communities to take the               from the MAPEDIR process include: arrangement of
necessary steps to save mothers.                         22 referral transport vehicles round the clock within
                                                         the government system, and operationalising seven
Strategies for Change                                    institutions to conduct deliveries. Nine more will be
Making change possible for mothers in places like        operational by the end of the year.
Muradpur is not easy. However, maps help to
pinpoint as well as highlight the maternal mortality     Health Audits by Panchayats in Guna
problem as seen in Box 11.                               MAPEDIR’s Catalytic Effect
                                                         MAPEDIR’s catalytic effect is being felt in the
MAPEDIR is being implemented in Guna and                 changes sweeping the Fatehgarh sub-centre in
Shivpuri. Both districts have the advantage              Bamori block. Provided the initial impetus for
of simultaneously serving as sites for another
innovative initiative known as ‘Village Planning’,
which seeks to integrate various developmental
schemes that have a bearing on maternal and child
health. It mobilises and empowers communities to
take charge and steer the changes.

On the ground, the first step is notification of
maternal deaths by the ANM, the anganwadi worker,
ASHA (the local village-level link-worker) or any
Panchayat member to the block. In Madhya Pradesh,
deaths of all females in the 13–49 age group are         Health audit by Panchayat in Guna

   Box 11: Mapping maternal deaths to awaken the community and service providers

   “we asked interviewers to put a red dot on the villages where maternal deaths were taking place in the
   district map of Guna. when they clustered the deaths, the picture became clearer. we found certain
   Primary Health Centres (PHCs) did not have a doctor and many sub-centres had unfilled posts of ANMs
   (Auxiliary Nurse Midwives). In many instances, vehicles were not available to transport the woman in
   labour to health institutions. In some sub-centres, ANMs were posted but did not possess adequate skills
   to conduct deliveries.

                                                                   MAPEDIR was an eye opener. It started
                                                                   telling us where women were dying and
                                                                   the underlying reasons. For example,
                                                                   Bamori block which is close to the
                                                                   Rajasthan border was one of the places
                                                                   where pregnant women were at high risk
                                                                   because of its remoteness. There were no
                                                                   trained personnel to conduct deliveries.
                                                                   It was clear that by upgrading one of the
                                                                   sub-centres (Fatehgarh), posting additional
                                                                   personnel, and putting them through
                                                                   training on skilled birth attendance (SBA),
                                                                   we would be able to save many lives.
                                                                   Moreover, maternal death mapping could
   be used to influence the district administration. when the Guna District Collector saw these maps and
   data, he was convinced of the need to equip all PHCs with vehicles which could be used to transport
   emergency obstetric cases to the referral facility.

   “The above data triggered corrective actions. The Guna district administration conducted a survey on
   availability of vehicles in the district from all sources and negotiated cost-effective deals. Now, we have
   vehicles regularly available for transporting pregnant women to hospitals in the district.”

   Dr Narayan Gaonkar
   Health Officer, UNICEF Office for Madhya Pradesh

change, the local Gram Panchayat now has taken              is dispatched immediately. Once we got a call
up the challenge of reducing maternal deaths. “we           from Digdoli village, 18 km away, in the middle
have worked out a mechanism for transporting                of the night. we were able to send a jeep within
pregnant women. The sub-centre gets phone calls             15 minutes of receiving the call and the expectant
from remote villages requesting for transport to            mother was brought to the Fatehgarh sub-centre in
bring a pregnant woman. It gets in touch with me;           time,” says Mohan Baghel, Vice Chairman of the
I contact the local vehicle owners and transport            local Gram Panchayat.

The sub-centre is being upgraded to a sector               women who died belonged to vulnerable groups.
Primary Health Centre (PHC) and the foundation             Half of them married at age 17 years or below,
laid for a regular labour room. All contracted staff       67 per cent were illiterate, and 55 per cent
at Fatehgarh has undergone training in skilled birth       were members of a scheduled caste or tribe,
attendance at the Guna district hospital, and has          versus 32 per cent of the general population.
started using a partograph, a tool used to assess          Also, 62 per cent of the women’s families were
the progress of labour and the need for intervention.      BPl card holders, but only 24 per cent knew
The AYUSH dispensary, where postnatal women                about the BPl referral transport benefit.
stay, now provides medicines to postnatal women
to increase lactation and to prevent post partum           2. Timing and Causes of Death and Access to
haemorrhage. The community is glad that the                Skilled Assistance
Fatehgarh centre is now available 24 hours a day           As much as 97 per cent of the 92 analysed
for deliveries: otherwise they would have had to go        maternal deaths occurred during labour and in
to Bamori or Guna, or as before, many would have           the post partum period, with 30 per cent women
been forced to have home deliveries assisted by            dying more than 24 hours after delivery. Most
traditional untrained birth attendants.                    deaths were due to causes directly related to the
                                                           pregnancy, including 29 per cent from haemorrhage,
“The Fatehgarh experiment has been a huge                  27 per cent eclampsia, 9 per cent septicaemia,
success. Once we have shown results, we can                and 8 per cent obstructed labour. Amongst indirect
argue for more funds for vacancies to be filled            causes, 10 per cent died of anaemia and 12 per
up,” says Guna CMHO Dr Raghuvanshi. UNICEF                 cent by other causes. Five per cent of the deaths
had supported the additional staffing of Fatehgarh         were due to undetermined causes. 36 per cent
sub-centre for a year. Now for the year 2007-08,           of the deliveries took place at home, without the
all the staffing cost is incorporated in the district      benefit of a skilled birth attendant.
health budget of RCH II, says Ms. Rohini Jinsewale,
UNICEF Extender in Guna district.                          3. Decision Making in Respect to Accessing
                                                           Formal Care
Improved Mobility                                          Nearly one-third (32 per cent) of the deceased
Based on the success at Fatehgarh (see Box 12), a          women never sought formal healthcare for their
referral transport model was initiated for emergency       illness, and another 10 per cent delayed formal
referral transport vehicles to be placed in institutions   care seeking by first taking another action. Not
conducting 24-hour deliveries in Guna district. with       recognising the severity of the illness was the
the support of NGOs, contact numbers of the drivers        leading reason (68 per cent) for not seeking formal
were made available to the community, enabling             care first or at all. The woman’s husband (45 per
families to call on them when needed.                      cent) and others in the household (48 per cent),
                                                           including her mother and in-laws, were the main
Notable Findings of MAPEDIR in                             persons to make this vital decision regarding care
Madhya Pradesh                                             seeking. Only 8 per cent of the women themselves
1. Demographic and Socioeconomic Indicators                took part in decision-making. Among those who did
In Guna and Shivpuri districts, 102 maternal deaths        seek formal care, half the families took 30 minutes
were identified and investigated from January 2006         or more to arrange for the woman’s transportation,
to June 2007, and the data for 92 were analysed.           and another hour or longer to travel to the first
The interview findings clearly showed that the             facility visited.

   Box 12: The Fatehgarh experiment

   Till November 2006, the Fatehgarh health sub-centre in Bamori block, Guna district, was staffed by a
   single ANM who conducted two to three deliveries per month. Most residents in surrounding villages had
   no choice but to go to the block PHC at Bamori, some 30 km away. Roads were bad. Public transport
   was almost non-existent – only one bus every morning. If there was an obstetric emergency, families
   were helpless. There were vast stretches with no access to a skilled birth attendant. Mapping maternal
   deaths pinpointed the pockets where women were dying due to lack of access to a health facility and
   where they were potentially vulnerable. The Guna district administration realised many lives could be
   saved by strengthening the Sub-centre. UNICEF pitched in by supporting two additional ANMs, and an
   lHV (a retired person, who was hired on a contractual basis) at the sub-centre. Equipment and drugs were
   provided by the district administration. The lHV and the two ANMs now live on the premises, the centre
   has become functional round the clock, and the number of institutional deliveries in the area has gone up.
   In December 2006, 23 deliveries were conducted at the revitalised sub-centre at Fatehgarh. In January
   2007, the figure went up to 32 and in March, it had reached 43.

   “Every day, we get four to five expectant women. They come in bullock carts, tractors, bus and
   sometimes by foot from surrounding villages,” says Mrs Komalavally, the lHV working at the sub-centre.

                                                        Many women like Ram Murti are happy that they can
                                                        have a safe delivery without having to go far. Ram Murti
                                                        gave birth to a healthy 2.8 kg baby girl in March 2007
                                                        at the Fatehgarh sub-centre. Her first three children
                                                        were born at home. But this time, the local ASHA
                                                        motivated her to come to a health facility. The cash
                                                        incentive of Rs 1,400 offered by the Janani Suraksha
                                                        Yojana (JSY) was a big attraction, admits Ram Nath,
                                                        her husband. But he is equally glad he did not have to
                                                        take Ram Murti to the Bamori block PHC, more than an
                                                        hour’s drive from his house.

4. Referral Facilities
More than two-thirds (69 per cent) of the women              a lack of resources and preparedness of the family
seen at a formal health facility were referred to a          for any eventuality associated with childbirth.
higher level institution, mainly due to complications
that were unmanageable at the first facility. The
average out-of-pocket expenditure for transportation         B. NUAPADA AND KORAPUT, ORISSA
and treatment at the first facility was Rs 300
(0–1,500). Families spent on average Rs 500                  Though rich in mineral wealth and natural beauty,
(0–3,000) for transportation and treatment at the            Orissa is paradoxically among the poorest states in
second facility. Most families had to borrow money           India. Acute poverty, widespread hidden hunger,
for hiring a vehicle to go to a health centre, indicating    and lack of basic services are severe obstacles to

    Living and dying on the margins                                              mother-in-law. when the placenta did not
                                                                                 come out, the family called a lady health visitor
    It is sundown. In a dry, barren village in                                   who took it out. Subsequently, the woman
    Khariar block in Orissa’s Nuapada district,                                  complained of pain in her limbs and a local
    a family is being interviewed about the death                                ‘practitioner’ (village quack) was called in. He
    of a 30 year-old woman who expired after                                     gave her an injection. The woman died seven
    delivering her fourth child. Official documents                              days after delivery. The ANM had spoken to
    classify the household as ‘below the poverty                                 the family about the Janani Suraksha Yojana
    line’. The family has a roof over its head but no                            and urged them to have the woman deliver at a
    education. Their home, a new brick structure,                                health facility. The family, however, argued that
    was built from the money sanctioned under a                                  three children were born at home earlier, and
    Government-assisted scheme. The deceased                                     there was no reason to go to a hospital. Even
    woman’s husband, a landless peasant, continues                               the monetary incentive was not compelling
    to eke out a livelihood as a loader. The earnings                            enough because the family feared there would
    are barely Rs 50 a day, thrice a week. The                                   be other costs which would not be covered
    family can just about afford a diet of rice, onions                          by the government scheme. The surviving
    and chillies. There is no money to buy milk for                              child is being looked after by the grandmother,
    the children. The nearest water source (tube                                 who, even today, has implicit faith in her
    well) is half a kilometre away. The family has                               ‘village doctor’.
    almost no contact with the health system.
                                                                                 This vignette from Nuapada brings home the
    As the interview of the mother-in-law and the                                daunting situation faced by the government’s
    husband progresses, a clearer picture emerges                                schemes to promote institutional deliveries and the
    about the causes and circumstances leading                                   circumstances under which the MAPEDIR process
    to the woman’s death. The deceased woman                                     is being put into place in some of India’s poorest
    had delivered at home with help from her                                     and most remote villages.

realising its full potential. The state is characterised                          implementing MAPEDIR. The other MAPEDIR districts
by vast inter-district disparities. The districts located                         are Bolangir, Kalahandi, Malkangiri, Nabarangpur,
in the coastal alluvial plain, mostly inhabited by non-                           Rayagada and Sonepur.
tribals, are far more developed than those located in
the interior, inhabited largely by tribal communities.                            Data on the percentage of women receiving skilled
                                                                                  attention during pregnancy underscores the disparities
Both Koraput and Nuapada have large tribal
                                                                                  across the state. An official source (DlHS 2002-2004)
populations, and fall within the under-developed south-                           pegs institutional delivery in Nuapada at 24.9 per cent
western part of Orissa known as the KBK region.                                   and in Koraput at 19 per cent. The percentage of
Currently, Koraput and Nuapada are among the eight                                women who received full antenatal care was 19 per
predominantly tribal Navajyoti districts in Orissa11
                                                                                  cent in Nuapada and 13 per cent in Koraput.

10 The District of Nuapada was a part of Kalahandi District until early March 1993, when for administrative convenience, Kalahandi District was
   divided into two parts i.e. Kalahandi and Nuapada vide State Government Notification No. DRC-44/93/14218/R. dated 27 March 1993.
11 Navajyoti districts are characterised by high IMR, tribal population, lack of health education, and lack of awareness about existing health facilities.

    Feedback	from	the	field:                                                non-biological or non-medical factors which
                                                                            make people stay at home or in places where
    According to an Orissa government official,                             the specific facilities to tackle this problem are
    “MAPEDIR will reveal to us what we do                                   not available. They stay there and die. Through
    not know. The present system tells us that                              this process, if we can pinpoint the specific
    so many mothers are dying of post partum                                reasons for maternal deaths in a district like
    haemorrhage (PPH) – the immediate medical                               Nuapada, then while formulating maternal health
    reasons. But this is not enough. To prevent                             strategies/interventions, the government can
    these deaths, we need to know a lot more.                               incorporate these factors instead of placing
    we need to know the situation at facilities –                           specialists everywhere… Right now, there is
    blood banks, ability of instruments, specialists                        no dearth of funds; but we have to use the
    at community health centres and so on.                                  resources in a way that can produce results…
    Sometimes the specialists are there, the                                The Orissa Government was convinced of the
    instruments are there, blood is available, but                          utility of this tool (MAPEDIR) and therefore
    patients do not arrive in time. So even if the                          implementation was extended to all eight
    system exists, we are not able to prevent the                           Navajyoti districts.”
    deaths because PPH is something which has to
    be treated within a limited time. If we cannot                          Dr Santosh Mishra, Deputy Director (Nutrition)
    act in time, life is lost. MAPEDIR will help                            and Nodal Officer, Navajyoti Scheme,12 Orissa,
    us find out the causes of delay of a mother                             echoes the same faith in the MAPEDIR process:
    reaching that health centre where we                                    “Being a gynaecologist, I know about maternal
    are providing so many facilities.                                       mortality and also infant mortality. In spite of
                                                                            many plans and projects, Orissa’s MMR and IMR
    “we have embarked upon many activities but                              remain very high. If the causes as well as our
    the desired results are not there because we                            shortcomings can be pinpointed, MMR and IMR
    are not hitting at the specific factors that are                        can be tackled effectively. MAPEDIR can help us
    responsible for maternal deaths. These are the                          use our manpower better...”

                                                                            low literacy levels, constitutes key challenges to
while existing data give broad indicators and the                           improving maternal health in both these districts.
aggregate picture, they do not offer sufficient insights                    The multiplicity of prevalent dialects further
into all the factors that lead to maternal deaths.                          compounds the demands on outreach work.

The early days of MAPEDIR in Nuapada and Koraput                            Naturally, a great deal of effort needed to be
(2005) offer valuable insights into some of the                             put in to create the right atmosphere to pilot
tough issues representatives have to grapple with in                        maternal death reviews in Nuapada and Koraput.
places where a healthcare-seeking culture is almost                         From January to June 2006, UNICEF supported
non-existent. This, along with low awareness and                            several state-level advocacy workshops in

12 The Navajyoti Scheme was launched by the Orissa Government in April 2005 to deal with the challenge of high neonatal mortality and to encourage
   institutional deliveries.

partnership with the Orissa branch of the white        with the family as their way of asking questions.
Ribbon Alliance. These were occasions to sensitise     Therefore, good verbal communication skills and
key stakeholders such as faculty members of            interviewing techniques were vital. Interviewers
medical colleges, officials from the state institute   were asked to empathise with the circumstances
of health and family welfare, UN agencies, NGOs        of the family where a maternal death had taken
and state officials.                                   place. They were asked to frame the questions in
                                                       a manner that would not hurt the bereaved family.
Discussions aiming at convergence between the          The accuracy of reporting was also emphasised.
IMR mission and MAPEDIR had started earlier.           “If we do not want this to become another
Meetings were also held to sensitise district          stereotyped government programme, we have
officials on the MAPEDIR process. Training of          to invest time so that we get the correct answers.
district level investigators began in April 2006       we should be very clear that the information
and lasted till the end of the year.                   we gather is in accord with the actual events,”
                                                       adds SC Mishra.
Grassroots Efforts
Initially, MAPEDIR encountered strong resistance
in both Nuapada and Koraput. In many instances,        People, Partnerships and Possibilities:
interviewers discovered that families where a          Forging Linkages, Strengthening Systems
maternal death had taken place did not want to         NGOs in Orissa have emerged as an important
speak at all. Many families said “The dead woman       institution playing a vital role in social development
has gone. She will not come back. why are you          and improved healthcare delivery. A key feature
asking so many questions?” The response was            that can be counted as an achievement in Nuapada
not surprising because health services were not        is the unmistakable enthusiasm of the District
reaching these remote rural communities, admit         Project Management Unit (NRHM) and of Srusti,
officials. So the advice to the interviewers was:      the local NGO whose partnership offers much-
“when you get resistance, do not persist on            needed support for evidence-based advocacy and
asking questions. leave them alone. later you          monitoring, which are an essential feature of the
must go back.”                                         MAPEDIR process. Srusti, an affiliate of the white
                                                       Ribbon Alliance for Safe Motherhood, is ideally
“If you go to a remote tribal village and ask          situated to spread awareness about key issues
the questions in Oriya (state language), no one        affecting maternal health.
will understand. Therefore, in KBK districts
interviewers must frame the questions in local         At present, it is too early to gauge the extent of
dialects… In the group discussions, many of the        the impact of MAPEDIR on maternal mortality
interviewers were encouraged to ask questions in       ratios in specific districts in Orissa but it has set
local dialects,” observes Dr Suresh Chandra Mishra     in motion processes that could have a lasting
(previously the Nodal officer for the Navajyoti        impact. For example, health workers point out that
scheme), who oversaw the MAPEDIR process in            the concept of the ‘3 delays’ underlying maternal
Orissa in its early phase.                             deaths is getting better known. MAPEDIR is also
                                                       generating awareness about government schemes
During the training session, it was impressed upon     such as the Janani Suraksha Yojana (JSY). Further,
the participants that the outcome of the maternal      the community-based social audit of maternal
death review depended as much on their familiarity     deaths is being carried out with the support of

the Health and Family welfare Department, the             mortality in my area: bleeding, obstructed labour,
Department of women and Child welfare as well             sepsis, toxaemia and anaemia. But after my
as NGOs. This is forging bonds and helping to             training in MAPEDIR, I also came to know about
identify bottlenecks. “It is telling us where we          the non-medical reasons for maternal deaths: the
need to strengthen our services and infrastructure.       three delays. Now I know that delays can be at
As a result of MAPEDIR, we are becoming more              three levels – the delay in decision-making at the
alert. Blood storage facilities in health centres are     family level stemming from lack of awareness
improving and first referral units (FRUs) are getting     about danger signs, the delay in transport from
strengthened,” says Dr Santosh Mishra.                    home to facility and in referral transport from one
                                                          facility to another facility, and finally the delay
The wake-up call is not just for officials but also for   in receiving medical care after reaching a health
communities. In Koraput, a key factor contributing        facility,” she elaborates.
to maternal deaths is lack of transport from remote
villages to health facilities. “In the tribal pockets,    Following the launch of MAPEDIR, ASHAs – the
many women die of post partum haemorrhage                 local village-level link workers have been directed
because they are severely anaemic. On top of that,        to arrange for referral transport at the first stage
they deliver at home with the help of untrained           of labour pain in a woman. This, Panda hopes, will
attendants. But now, we hope local evidence               save many lives.
generated by MAPEDIR will convince people to
go to hospitals. Fortunately, awareness about             State Action
government incentives for institutional deliveries is     “A recent government directive states that in case
also increasing”, adds Mishra.                            of obstetric emergency, the Block Development
                                                          Officer (BDO) can arrange referral transport. The
Notable	findings	of	MAPEDIR	in	Orissa                     need is at its most acute during the rainy season
A Snapshot from Koraput                                   when roads are flooded. So transport arrangements
“In 2003-2004, the recently upgraded PHC at               have to be requested and planned in advance. At
laxmipur reported 60 institutional deliveries. In         the block level, once in every two months, we are
2005-2006, the figure had shot up to 221. Much            also conducting PRI meetings to review progress
of the change is due to the monthly meetings              and familiarise ourselves with the new initiatives
held at Gram Panchayats. During such meetings             and schemes,” says Sudhakar Buroi, Block
we promote greater awareness about the reasons            Development Officer, laxmipur
behind maternal and infant deaths and the benefits
of JSY which supports institutional delivery,” says
Indira Panda, a lady Health Visitor working at the           “One of the biggest barriers is lack of
upgraded PHC at laxmipur block.                              knowledge. Health-seeking behaviour is almost
                                                             absent in many rural areas. Making families
MAPEDIR is helping tone up the Koraput district              think that a maternal death is an issue at all, is
health system through an orientation training                the single biggest challenge.”
programme for health workers. Panda, an lHV,
says her understanding about the maternal deaths             Biswajit Padhi
in her area has increased appreciably after the              Head of Srusti, UNICEF’s NGO partner in
training and after investigating a few maternal              Nuapada
deaths. “I knew the medical causes of maternal

MAPEDIR Initiatives and Impacts                            In the field, health workers are up against many
MAPEDIR, in conjunction with other initiatives, is         more hurdles. Sometimes those who need to
setting up a State Maternal and Child Survival Cell        be interviewed are not present despite prior
with an independent consultant to oversee Skilled          appointments. As daily wage earners, they cannot
Birth Attendance (SBA). Along with Prevention of           afford to let go of any work that comes their way.
Parent to Child Transmission (PPTCT) of HIV and            This necessitates repeated visits by health workers,
Malaria, MAPEDIR is helping bring about many of            which creates its own logistical challenges, as
the changes envisioned under NRHM and RCH II.              interviewers often do not get adequate mobility
UNICEF is part of the effort to train skilled birth        support/remuneration to go to places that are already
attendants in Koraput and other Navajyoti districts.       handicapped by poor road connectivity and which
It is also supporting operationalisation of FRUs.          get waterlogged during heavy rains.
Blood transfusion facilities have already been
strengthened in 35 FRUs in Navajyoti districts.            These and related issues came to the fore at a recent
                                                           meeting of MAPEDIR interviewers, presided over by
Some Instructive Inferences and Pointers                   the Srusti representative and the District Programme
The relatively slow pace of the MAPEDIR rollout in         Manager of the National Rural Health Mission at
Orissa underscores the need for better coordination        Nuapada. Feedback from the field pointed to the
between health schemes and ICDS in some blocks,            urgent need to step up supervision at every stage of
and between the District Programme Manager                 the MAPEDIR roll out. without adequate supervision
(DPM) who is responsible for overseeing initiatives        of data collection, data analysis and data sharing,
under the National Rural Health Mission, and the           scaling up MAPEDIR across eight poor and backward
Chief District Medical Officer, the face of the public     districts would become an exceedingly difficult task.
health system in a district.
                                                           An important lesson from the experiences in Nuapada
Frequent transfer of key officials at the state- and       and Koraput is that enthusiasm at the state level
district-level is a key bottleneck, standing in the way    does not automatically percolate down to the rank
of an administration really taking ‘ownership’ of a        and file in the districts. Special efforts have to be
public health intervention. There is also persistent       made to bring the district bureaucrats on board.
fear amongst some that an improved maternal death          There is an urgent need to sensitise district health
reporting system may not be politically expedient in the   officials, especially the Chief District Medical Officer,
short term. All this is often superimposed on general      about the significance and benefits of MAPEDIR.
apathy characteristic of government departments.
                                                           In recent times, however, there have been some
Ground-level challenges confronting health workers         signs of progress. Anecdotal evidence from the
include weak health systems and a situation where          Navajyoti districts, cited in this working paper,
most rural women still prefer to seek care from a          suggests a movement forward. The rate of
variety of non-professional sources when they are          institutional deliveries in the state as a whole has
in trouble during pregnancy and childbirth. Crushing       gone up from 23 per cent during 1998-99 to 39 per
poverty combined with lack of education and                cent in 2005-2006, according to the latest National
awareness create a deadening apathy in which the           Family Health Survey (NFHS - III). Rural women
biggest challenge, as Srusti’s Head, Biswajit Padhi        even in remote villages in a tribal dominated district
points out, is to make communities perceive maternal       like Koraput are coming forward and opting for
and child survival as worthwhile goals.                    institutional deliveries.

 Saving mothers and children in the                    Dholpur by a local NGO, Mangalam Sewa Samiti.
 desert state                                          Ashok Tiwari, who heads the NGO got the idea
                                                       of the 24-hour Helpline for obstetric emergencies
 Health workers seldom visit Biharipura. This          when Mangalam, guided by UNICEF, started
 remote village in Rajasthan’s Dholpur district has    MAPEDIR in two blocks in Dholpur in 2005.
 100 inhabitants, mud huts and no electricity.         “we realised that the past deaths could have
 The Chambal ravines, infamous for infestation         been prevented. we also realised we were in a
 by outlaws, are close by; and a road journey          unique position to intervene and stop such deaths
 can be risky. The nearest health centre is 6 km       in future. we knew the local people, we were
 away. Yet here, amongst families of subsistence       familiar with the government structures, and we
 farmers, one can strangely feel the catalytic         also knew what facilities were available locally.
 effect of MAPEDIR.                                    Then, we looked back at the three delays that
                                                       caused the maternal deaths we had investigated
 In January 2007, Geeta, an unlettered woman           in the district.”
 from Biharipura, delivered a healthy baby at
 the nearest community health centre (Bari             “The next stage was setting up interventions at the
 block). within three hours of delivery, she was       local level to deal with each delay. The first delay
 haemorrhaging. Geeta would have died but for          is at the family level. So, we started sensitising
 the birth preparedness plan the family had worked     families about danger signs during pregnancy and
 out when Geeta was seven months pregnant. So,         impressed upon them the need to act quickly. we
 unlike most rural households in India, they did       told them the birth of a child in the family required
 not waste time. Geeta’s family had a telephone        planning and we helped them develop a birth
 number they could call during an emergency –          preparedness plan. This was a contingency plan
 the 24-hour Janani Suraksha (Safe Motherhood)         keeping in mind the sudden need for various things
 Helpline. The doctor at the Bari CHC also sent an     – money, blood, transport,” says Ashok Tiwari.
 SOS advising Geeta’s immediate referral to the
 Dholpur district hospital as the CHC did not have a   To be sustainable in the long-term, the initiative
 blood bank. The Helpline Coordinator arranged for     also required the involvement of a health worker
 transport within minutes and Geeta arrived at the     or a local village level motivator like the ASHA
 Dholpur district hospital.                            Sahyogini. So Mangalam and UNICEF persuaded
                                                       the then Special Secretary Health, who also
 Timely blood transfusion and medical care             headed the state chapter of the National Rural
 saved the mother and her baby. The family             Health Mission, to issue a directive to Dholpur’s
 redeemed the expenses they had incurred on            Chief Medical and Health Officer and the District
 transport from the money they got from JSY,           Programme Manager of NRHM, to support NGO
 the central government’s scheme for providing         initiatives. Thereon, it became easier, recalls
 cash assistance to pregnant women who opt for         Tiwari. Today, traditional birth attendants trained
 institutional deliveries.                             as “motivators” by Mangalam escort pregnant
                                                       women to government health facilities for delivery,
 This happy turn of events was not a coincidence.      saving mothers and children from an untimely and
 It was the result of sustained efforts in rural       preventable death.

The next steps in taking MAPEDIR forward
in Nuapada and Koraput include involving the         The	first	steps	
District Collector more closely with the process
at the district level and advocating more strongly   “we felt it was important to have unbiased
with the Director of the National Rural Health       parties collecting information in order to gain
Mission and the Department of Family welfare         accurate insights into the circumstances
at the state level. The ongoing partnership with     leading to maternal deaths. local civil society
the state chapter of the white Ribbon Alliance       representatives were neutral parties and
is expected to accelerate implementation,            potential partners.
and strengthen monitoring and community
sensitisation. The UNICEF State Office’s alliance    For us, this was also a valuable opportunity
with the Orissa Red Cross Society and the State      to enhance the capacity of the civil society
Blood Transfusion Unit will also be leveraged        on maternal death issues. we, therefore,
to strengthen the blood transfusion services         initiated the process of maternal death
at First Referral Units as part of toning up the     enquiry by building the capacity of local
health system – one of the key objectives of the     NGOs to collect accurate information in a
MAPEDIR process.                                     scientific manner. The process was initiated
                                                     with Mangalam Sewa Samiti in Dholpur.
                                                     This was our learning and testing ground.
C. DHOLPUR, RAJASTHAN                                The analysed data was shared with the
                                                     community and other stakeholders. This
The maternal mortality rate in Rajasthan state       inspired the creation of the Janani Suraksha
has declined from 508 in 1997-98 to 445 in           Helpline. The feedback from the community
2001-2003, but is still significantly higher than    helped us generate awareness of danger
the country average of 301. women die during         signs and birth preparedness. Subsequently,
pregnancy, childbirth, and soon after, due to        several civil society networks in other
medical causes that are well-documented. But the     districts were also trained in MAPEDIR.
silent tragedy persists in the countryside because   These were Action Research and Training
the underlying causes of unsafe motherhood are       for Health (ARTH) in Udaipur; Shiv Shiksha
often not adequately addressed. Saving mothers in    Samiti in Tonk; PRAYAS network in
Rajasthan entails battling nature and prejudice      three districts viz., Barmer, Dausa,
side by side.                                        Dholpur; and ARAVlI network in Baran
                                                     and Jhalawar.
A maternal death is an extreme consequence of
the widespread neglect of women in the state,        To date, about 50 persons have been
but there are other telling indicators of male-      trained in implementing MAPEDIR and
female differentials and the low status accorded     72 maternal deaths have been reviewed
to most women. Many districts in Rajasthan           (40 in Dholpur, 15 in Udaipur, and
have an adverse sex ratio for females pointing to    17 in Tonk).”
widespread and illegal female foeticide. In 1991-
2001 Rajasthan recorded the highest growth in        Dr Pavitra Mohan
literacy rate in India, moving from 38.6 per cent    Project Officer, UNICEF, Rajasthan
to 61.03 per cent. But the female literacy rate is

41.8 per cent, and literacy levels, especially for
girls, remain among the lowest in the country.                                “Our workers faced resistance at the start
The health indicators of the district are telling:                            because of entrenched attitudes and the
According to the District level Household Survey                              prevailing low status of women, lack of
(DlHS 2004), Dholpur has a high birth rate                                    education, low awareness, illiteracy, cultural
(26.53). The mean age at marriage for girls is 17.4                           practices, beliefs etc. But then when we
years. Only 39 per cent of all deliveries                                     started telling people about what we had
were conducted by skilled birth attendants                                    uncovered while reviewing maternal deaths
(DlHS, 2003-2004).13                                                          in this very district, they started to listen.
                                                                              we did not use technical language, nor
A common thread runs through the stories of                                   go into too many details. But we shared
maternal deaths in rural Rajasthan: the women                                 the broad findings – that were within
who died had little control over their lives, minimal                         everyone’s grasp. These deaths were taking
access to basic services, and little exposure to the                          place around them, and we told them the
outside world. The deceased were victims of gross                             underlying reasons. It is this local evidence
neglect either by their families or their community                           that snapped people out of apathy. Earlier,
or the health system – sometimes, all three. The                              people had never really linked their actions
circumstances that led to their death are not                                 to the deaths. But when we started pointing
unique to Rajasthan. But they are exacerbated                                 out the linkages, they started thinking
by the state’s poor infrastructure, weak health                               differently. In one instance, there was no
system, scattered population, and socio-cultural                              one at home to take a decision where to take
practices that continue to discriminate against                               the expectant mother, and the woman bled
girls and women.                                                              for two hours. The family did not perceive
                                                                              this as a ‘delay’ because they believed that
In 2008, maternal survival therefore remains                                  bleeding was normal… and did not see any
one of the most pressing challenges confronting                               danger in a woman bleeding for two hours
the desert state as it seeks to carve a new                                   or so. They were simply unaware of danger
future for itself, and better its record in                                   signs and the village dai had told them
human development.                                                            not to worry.”

Implementation                                                                Ashok Tiwari, Mangalam
MAPEDIR was initiated as a modest initiative in
one block of Dholpur district in 2005 (Baseri)
and extended to another block (Bari) in 2006.                             Initial Resistance
It is one of three districts in Rajasthan currently                       As maternal deaths began to be scrutinised, it
implementing MAPEDIR. The other two districts                             became apparent that something had to be done
are: Tonk and Udaipur. In preparation of the                              to overcome pockets of localised resistance.
project, the first Training of Trainers session                           This resistance was not unique to Dholpur but
took place in June 2005, and the first batch                              surfaced in varying degrees in almost all MAPEDIR
of MAPEDIR interviewers were trained around                               districts in the country in the early days. As death
October in the same year.                                                 inquiries strengthened the death reporting system,

13 District level Household Survey (DlHS) conducted under the aegis of the Government’s RCH Programme.

many within the establishment feared reprisals in      the women), sepsis (20 per cent), and anaemia
case instances of neglect came to light. UNICEF        (16 per cent). A significant number of maternal
Rajasthan and Mangalam overcame some of                deaths occurred either on the way to the health
these teething problems by advocating for the          facility or in-between the facilities. Typically there
verbal autopsy tool with the highest authorities       was delay in transportation.
in the state government while also seeking their
assurance that no penalisation would take place.       The key messages emerging from the maternal
Eventually the data generated by the maternal          death inquiries are that the delays in seeking care
death reviews in the two blocks in Dholpur             and reaching the appropriate health facility need
provided powerful ammunition to win over the           to be reduced. This can be accomplished by
community’s as well as the government’s backing        promoting awareness of how to recognise
for MAPEDIR.                                           the signs of an obstetric emergency and actions
                                                       to be taken, including planning for transport
Case studies were shared with the community            availability, knowing where to take a woman at the
during Jan Sunwais (public hearings) in Dholpur and    time of an emergency, and setting aside funds for
in Jaipur, the state capital. UNICEF officers shared   emergency care.
the analysed data with top health officials in the
state and advocated strengthening of state-wide        Obstetric Helpline
notification of maternal deaths as well as official    Following the death reviews in Dholpur, hundreds
support to the death inquiry process.                  of participants gathered together in dozens of
                                                       village-level and multi-sector government meetings
As a result, large increases were seen in maternal     to discuss the findings of the death inquiries and
death notification. By October 2007, about 70          possible actions. Realising the importance of a
deaths were investigated and analysed across           functional referral transport system in saving the
Dholpur and Udaipur districts. The data emerging       lives of pregnant women in an obstetric complication,
from the inquiries have brought forth several issues   the district administration partnered with UNICEF
for local action.                                      and a local NGO to set up an “obstetric helpline”
                                                       (see Box 13) throughout the district. Networking
Notable Finding of MAPEDIR in Rajasthan                of various private and public vehicles and locally
Demographics of Maternal Death                         identified mobile phones forms the core infrastructure
Around 44 per cent of the maternal deaths in           of the helpline, which has been made financially
Dholpur occurred at the deceased woman’s or her        sustainable by linking it with JSY.
relatives’ home and 28 per cent on the way to a
health facility; 85 per cent of the deaths occurred    Chain Reaction
during labour or within 42 days of delivery. More      while Dhanukapura showcases the powerful
than 50 per cent of families experienced a first       catalytic role that MAPEDIR and its partners
delay greater than one hour, and about 40 per cent     can and do play, much still remains to be done.
experienced a second delay greater than one hour;      As Rekha Devi, an ASHA worker points out
60 per cent of the deceased women were grand           “There are families where no one is literate. And
veterans of four and above, pointing to the effect     awareness levels about maternal and child health
of multiple births on maternal survival. The most      are very low. Some families would not even let an
important causes of death were APH (ante               infant be weighed because they believe it would
partum haemorrhage) or PPH (40 per cent of             attract evil spirits!”

 Box 13: Janani Suraksha Helpline

 The 24-hour Janani Suraksha Helpline was launched In January 2006, about six months after
 maternal deaths had begun to be reviewed in Dholpur. Part of a package of interventions to reduce
 maternal mortality, the Helpline aims to lower maternal deaths by addressing the three critical delays:
 delay in deciding to seek medical care, delay in reaching a place where care is available, and delay in
 receiving appropriate care.

 First delay: Birth Preparedness – A team of five field workers contacts families of pregnant women
 in their work area and helps them prepare for the birth of the child. The team counsels the family on
 danger signs, alerts them about the need to arrange funds in advance for contingencies, transport,
 and blood, if necessary, and also informs them about the Helpline. A Birth Plan prepared by the field
 workers is kept with the family, while they retain a copy. To date, close to 40 per cent of all births in
 Bari block have been tracked.

 Second delay: Organising Transport – This is the crux of the remedial intervention strategy. In
 Bari, the physical distances between women and the reproductive health services are considerable.
 Vehicles are often not available at times of emergency or are expensive when available. To facilitate
 rapid referral during emergencies, the Helpline maps resources in every village in the block, listing
                                                                             every vehicle and phone in
                                                                             the village. The birth plan
                                                                             includes these provisions as
                                                                             well as the contact details
                                                                             of the owner of the vehicle.
                                                                             In case a vehicle is not
                                                                             available locally, the family
                                                                             is urged to call up the
                                                                             Helpline, which is manned
                                                                             24x7 by an NGO facilitator.
                                                                             The telephone number of
                                                                             the Helpline is given wide
                                                                             publicity through wall
                                                                             graffiti and other means.

 Third delay: Negotiating the Health System – One of the strongest elements of intervention
 is support for the families once they reach the hospital. There are times when a hospital
 has refused or failed to provide quality medical care, and the concerned families have
 approached the district collector to intervene. Interventions from the Helpline have helped too,
 with the resultant benefit of a better interface between the community and the
 health system.

                                                            government officials and an NGO representative are
   “If we find that in a particular place, most             being set up in four districts to offer relevant advice
   deaths are due to delays in decision making              to their district health societies.
   at the family level, we know that behaviour
   changes are urgently required. And we can                Lessons Learned
   strengthen the work of the village link worker           The biggest challenge on the ground is the lack of
   or ASHA sahyogini and the ANMs. we also                  knowledge and awareness about factors contributing
   need to know whether delay due to lack of                to maternal deaths among rural households. A lot more
   referral transport is at the level of the first          needs to be done to bridge the gaps in awareness
   health facility or the second health facility.           among about the need to take appropriate action in
   The bottom line: we need information which               the event of an obstetric emergency and to take the
   tells us which interventions need strengthening          woman to the right health provider on time. Much
   and where. If the delays are at the facility-level,      more also needs to be done to mobilise communities
   then the facilities need strengthening.”                 and the health system to ensure that money and
                                                            transport services are available in an obstetric
   SP Yadav                                                 emergency. The MAPEDIR evidence points as well
   Director (RCH), Directorate of Medical and               to the need for greater awareness of government
   Health Services, Rajasthan                               schemes and incentives to encourage women to
                                                            deliver at institutions and ensure safe motherhood. The
                                                            data also raises ethical issues and concerns about the
Partnerships with NGOs, Asha Sahyoginis, existing           quality of care disbursed by the public health system.
governmental schemes and workers have been vital
to building a strong community base for MAPEDIR.
                                                               “For the past two years, I have been visiting
As a result of the MAPEDIR process, many more                  10 houses every day. wherever there was
families are receptive to the idea of birth preparedness       a pregnant woman, I drummed the message
plans. Even as the 24-hour Helpline has gained in              of the need for regular antenatal checkups,
popularity, communities are themselves taking charge           and the need to be aware of potential
of their own destiny (see Box 14), arranging their own         complications. A lot of my time went to
village-based referral transport and calling the Helpline      making families aware of the danger signs
in the most critical cases. Forty vehicles are now on          that can potentially put a woman at risk
call for referral transport during obstetric emergencies       during pregnancy, childbirth or soon
across 170 villages in Dholpur’s Bari block.                   afterwards. I also stressed the need for
                                                               adequate nutrition because anaemia is widely
State Action: Strengthening the System                         prevalent. Families are poor so you have to
Based on MAPEDIR’s success, a directive making                 tell them about vegetables and fruits they can
maternal death notification and audit compulsory               afford. Many pregnant women have to work in
has been drafted and is being reviewed by the state            the fields and I reminded them to take care of
government. The maternal safety helpline has been              their diet and to take enough rest.”
scaled up to cover the whole of Dholpur district and
MAPEDIR is lately also being implemented in Udaipur            Rekha Devi, the village ASHA
district. In addition, death inquiry teams including

   Box 14: A community becomes proactive

   This was no commercial blockbuster. But a film on maternal death so stirred Surendra Singh
   Chauhan, a resident of Dhanukapura village in Dholpur district that he spontaneously volunteered
   the use of his jugaad for obstetric emergencies. Chauhan’s jugaad (a diesel-operated vehicle
   made locally by modifying irrigation pump sets) is normally used to transport cattle and grains
   to the market.

   “when I saw the film some five months ago, I was convinced I could help prevent mothers from
   dying… I charge a nominal Rs 250 for each trip to the Bari Community Health Centre. In the last
   four months, I have rushed four expectant mothers to the CHC,” says Chauhan.

   Dhanukapura, a village of 2,000 inhabitants was one of several sites in Rajasthan where a UNICEF-
   supported video film was screened to raise awareness about maternal deaths. “wherever the film
   was shot, villagers were keen to know more about maternal deaths and the services/facilities they
   could tap into to prevent such tragedies,” says OP Singh, UNICEF consultant.

   Though Dhanukapura has not had a maternal death in recent years, the film spurred the villagers
   into action. Field workers of Mangalam and UNICEF mapped the number and type of vehicles in
   each village in Dholpur. Next, transport owners/operators were contacted to find out the rates
   and availability of vehicles at the block level and to fix a standard tariff to avoid bickering and
   bargaining. The NGO workers also advised the police not to stop or harass vehicles transporting
   women requiring emergency obstetric care.

   Today, Dhanukapura has a fleet of three motor vehicles, two tractors, and one jugaad to rush
   expectant mothers to a health facility in case of emergency.

Follow-up Action                                         Promising examples are evident in Udaipur where,
MAPEDIR has the potential to mobilise civil society      with UNICEF support, the District Heath Society
and communities around maternal health. That it          has set up a system of 100 per cent maternal death
can be scaled up state-wide through civil society        notification and inquiry. The Society (chaired by the
networks, is being proved by the Dholpur model.          Collector) is committed to review each maternal
However, greater advocacy is needed still to             death in the monthly meeting. Notification and
penetrate pockets of apathy within the community         inquiry have already started.
and system. Concretely put, this means following
up on the proposed directive to make maternal            Based on the project’s positive experience, starting in
death notification compulsory, building capacity         2008, UNFPA and UNICEF would together be supporting
of the health system to follow this directive, and       MAPEDIR in a few districts in Rajasthan. These and
supporting the NGO networks in implementing the          other partnerships are expected to promote greater
maternal safety helpline.                                success, scaling up and sustainability of MAPEDIR


A. Guna and Shivpuri, Madhya Pradesh
» Madhya Pradesh is a vast sprawling state with poor road connectivity, a dismal health system
  and a highly illiterate and poor population (37 per cent BPl compared to the national average of
  26 per cent), according an extremely low status to its women.
» Faced with a dauntingly high MMR and IMR, MAPEDIR partnered with already established
  developmental schemes like “Village Planning” to give impetus to its process.
» The MAPEDIR process has had a catalytic effect in inspiring communities and NGOs to work in
  tandem to provide a round-the-clock referral transport system for obstetric emergencies.
» Thanks to a newly alerted administrative machinery, health audits have been initiated in all Gram
  Panchayats of Guna district and upgradation of medical facilities at several health centres to
  handle round-the-clock obstetric emergencies have increased institutional deliveries and brought
  down maternal deaths dramatically.

B. Nuapada and Koraput, Orissa
» Blind superstition, diehard faith in ancient systems and ignorance of modern medical methods
  are naturally rampant amongst tribal families subsisting on less than five dollars a week in this
  cyclone-battered state.
» Keeping local attitudes and sensitivities in mind, MAPEDIR sought the support of Srusti, a local
  NGO and an affiliate of the white Ribbon Alliance for Safe Motherhood, which was ideally
  situated to spread awareness about timely healthcare intervention and institutional deliveries –
  key issues affecting maternal mortality.
» The advent of MAPEDIR in Orissa has strengthened the services and infrastructure of
  government departments: blood storage facilities in FRUs are improving and the rate of
  institutional delivery in the state has gone up from 23 per cent during 1998-99 to 39 per cent in

C. Dholpur, Rajasthan
» Saving mothers in Rajasthan entails battling nature alongside prejudice, since more than 60 per
  cent of the state’s land is an arid desert with scattered villages and poor road connectivity; and
  poverty combined with deeply entrenched biases against females affect women’s access to
  health services in large pockets made up of scheduled castes and tribes.
» Currently running in the Dholpur, Udaipur and Tonk districts of Rajasthan, The MAPEDIR process
  was initiated in June 2005 by building the capacity of local NGOs like Mangalam, ARTH,
  ARAVlI and PRAYAS to collect accurate maternal death information in a scientific manner.
» The data emerging from the inquiries brought forth several issues for local action at different
  levels: birth preparedness plans in families, financially sustainable maternal help lines in the
  communities and a directive making maternal death notification and audit compulsory at the
  state level.


As a country with one of the highest number             Government of west Bengal to consider
of maternal deaths, India’s success in reducing         expanding the scope of existing government-
maternal mortality is critical to meeting the           aided schemes such as JSY, to cover APl
global target approved and adopted by the United        (above poverty line) and BPl (below poverty
Nations as the fifth Millennium Development Goal.       line) women, including those in urban areas.
Though considerable progress had been made              The JSY integrates cash assistance for
earlier in reducing maternal deaths, the change is      antenatal, delivery and postnatal care in a
not so dramatic recently, and in many countries         health facility and is coordinated by a field-
giving birth continues to be most risky. Today,         level health worker. MAPEDIR is now part
in India, and more generally in South Asia,             of the official policy of the west Bengal
maternal mortality remains essentially a                Government – which can be gauged by
predicament of poor people, and a product               the state government’s decision to issue a
of poor healthcare delivery.                            directive that every maternal death be inquired
                                                        at the community level.
2007 marked the 20th anniversary of the Safe         •	 In Udaipur, Rajasthan, the District Health
Motherhood Initiative. This was a defining              Society has incorporated MAPEDIR as one of
moment also for India. with its vastness,               its activities and it now figures in the agenda
diversity and complexity, India encapsulates the        of the Society’s review meetings. As of July
obstacles and the opportunities that lie ahead          2007, the district administration had started
in the battle for safe motherhood in developing         carrying out verbal autopsies of maternal
countries. Political will, passionate commitment        deaths in four blocks of Udaipur district,
and innovative policies and practices can               namely, Jhadol (Sarada), Salumbar, Sanwad,
transform India while providing a better future         and Vallabhnagar. To strengthen the capacity
for its mothers and leading the way for similarly       of the district health system to conduct the
situated women in other countries struggling            death inquiries, the assistance of NGOs such
to win the battle for survival. Failure to do so        as ARTH has been sought in two blocks,
seems inexcusable when millions of women                while in the other two blocks the district
are being senselessly lost to a certain but             health system is directly conducting
preventable death from the complications of             routine notification and verbal autopsy
pregnancy and childbirth.                               of maternal deaths.
                                                     •	 In Madhya Pradesh, the MAPEDIR process led
In turning the spotlight on the unseen and unsung,      to the initiation of health audits in all Gram
MAPEDIR is speeding up the process within the           Panchayats since January 2007. Such audits
country while building on excellent local models        review five main issues: maternal deaths,
(Chandigarh, Tamil Nadu). The information and           ANC registration and checkups, immunisation
insights emanating from the community-based             coverage, institutional deliveries, and cataract
social audit of maternal deaths are sparking            detection and operations in the panchayat
change in some of India’s most desperately poor         limits. Other welcome fall-outs from the
and remote pockets. Some notable examples of            MAPEDIR process include: Arrangement
this transformation:                                    of 22 referral transport vehicles round the
                                                        clock within the government system and
•	 In Purulia, West Bengal, preliminary findings        the operationalising of seven institutions to
   from the MAPEDIR process convinced the               conduct deliveries (both in Guna block).

   Nine more will be operational by the end           who are answering them are new to the concept
   of the year.                                       of tracking the sequence of events contributing to
                                                      the maternal death. Part of the challenge facing
In many other cases, communities have been            MAPEDIR is to acclimatise interviewers with the
transformed by the interview process. Village         format of the questionnaire. Many health workers
councils are holding meetings to discuss the          who are currently collecting data on maternal
findings from the maternal death reviews,             deaths are not used to filling up questionnaires
developing interventions such as the community-       requiring detailed responses to such events. In
based emergency referral transport system in          many cases, the families have never thought
Purulia. In Dholpur, village-level transporters are   about the issues brought to the fore by the
now part of the movement to save lives. Such          social audit; in others, they are on the defensive,
local action has kept the emergency transport         fearful of being blamed for neglect. In such a
systems operational even through civil unrest         context, UNICEF experience indicates that it is
and crises situations, saving the lives of many       imperative the interviewer succeeds in allaying
mothers who may not have otherwise made it            their fears and creating a comfort zone in which
to a health facility.                                 the respondents speak freely.

Maternal death reviews are narrowing the              where families and communities are constrained
knowledge gap. The process of interviewing and        not only by resources but also by illiteracy
being interviewed has led to greater awareness,       and cultural inhibitions, a critical need for the
not just among women and families, but also           interviewer and others implementing MAPEDIR is
among health personnel. In addition, MAPEDIR          to educate and sensitise them about the basics
has been instrumental in making invisible             of health, hygiene and maternal health. without
problems visible and fostering wider use of           this preliminary spadework, families are unable
governmental programmes and provisions on             to grasp the meaning of many questions and
maternal safety among communities who were            therefore cannot fully participate in the maternal
unlikely to benefit from it in the past.              death social audit.

In less than three years, MAPEDIR has proved its      Teething problems of the maternal death
potential in more than a dozen districts across       audit process also include the lack of smooth
India where women are at high risk during             functioning of the computer software for
pregnancy and at childbirth. But much more needs      processing and analysing the MAPEDIR data.
to be done for the early phase achievements to        This is now being tackled through corrective
be consolidated and obstacles to be turned into       measures such as training and orientation of
opportunities. Field visits to six districts in the   the interviewers and others in the software’s
first quarter of 2007 helped identify many of the     application. Another challenge is stepping
missing links. In 2008, more districts and more       up awareness among state and district level
states started to expand the model.                   bureaucracies about the ground-level reality for
                                                      poor, pregnant and powerless women and the
Some Necessary Spadework                              significance of MAPEDIR. In some states, the
The competence of the MAPEDIR interviewer is          state governments have given an enthusiastic
central to the success of the tool. In most cases,    reception to MAPEDIR but this stance needs to
those who are asking the questions and those          percolate down to district administrations.

In the early stages, a key problem is the fear         driven transportation initiatives for expectant
of local bureaucracies about the tool’s role in        mothers. Since SHGs are already involved in thrift
pushing up maternal death statistics. This is a        societies and income generating activities, they
sensitive issue. Much of the resistance witnessed      can generate emergency funds at the grassroots
towards effective implementation of the MAPEDIR        and shape the sustainability of initiatives triggered
process is connected with this fear which needs        by the maternal death audits.
to be addressed and overcome. It must be
impressed upon the district administration that in     As in most development projects, partnerships
the early stage, MAPEDIR will improve maternal         are central to the success of MAPEDIR. The
death reporting. As a result, on the surface, it       participation of NGOs has certainly kick-started
may appear that more maternal deaths                   the MAPEDIR process in the districts where it
are taking place. The same perspective has to          operates, but for long term sustainability, there
be conveyed to the public and policy makers            has to be a closer involvement of the District’s
so that they appreciate the process and are not        Chief Medical Officer and his team in every
suspicious of it.                                      district of every state. Refresher trainings are
                                                       also required in districts where there has been
The biggest challenge to competent tackling            a long gap between the original training and
of the audit is supervision of the death               implementation. The newly recruited ASHAs are
review process. Even with the best of efforts,         village-level assets and should be involved more
interviewers will falter if they are not supervised    intensely in the MAPEDIR process.
regularly. A diligent overview can take place only
when the local administration takes full ownership     The Next Steps
of the MAPEDIR process and views it as integral        In India as elsewhere maternal deaths happen due
to its broader human development goals and             to a combination of inter-related factors. The road
strategies. Further, in districts where there has      ahead is about innovating together, with different
been almost no supervision since the inception of      agencies leveraging their core competencies and
the programme, partnerships need to be forged          working with communities, empowering them
with local institutions such as faculties of medical   to achieve the common goal. MAPEDIR is not
colleges. These links can then be leveraged for        happening in isolation and not only because of the
district-level monitoring and supervision.             support of any one agency. It is a part of existing
                                                       convergent efforts to reduce maternal deaths. The
So far, this has happened most visibly in Purulia,     process is unfolding in a context where the federal
based on which experience, several tested ways         government, state governments and many district
have emerged to take the MAPEDIR strategy and          administrations along with health professionals,
components forward. Although poor, the district        researchers, academics, civil society networks, and
of Purulia had the advantage of a socio-political      other partners are taking steps to promote care-
context which encouraged the development               seeking behaviour and institutional deliveries to
of community-structures and Panchayati Raj             boost maternal and child survival. The interlinking
institutions. These are now yielding results. Other    of all these entities will remain a priority for
districts and states need to similarly strengthen      MAPEDIR and a prerequisite for its success.
their community structures. women’s self-help
groups (SHGs) do and can play a critical role in       At the micro-level, the next steps are to simplify
spreading awareness and organising community-          the questionnaire, making it easier to administer

in the new states and districts where MAPEDIR           management of human and financial resources.
will be launched; and for districts to strengthen       As institutional deliveries increase on account of
supervision of the interviewing process. The first      government schemes such as the JSY and due to
step has already been taken: a simplified, shorter      the catalytic role of MAPEDIR, there is pressure
questionnaire has been developed, field tested          to upgrade the institutions and build capacity on
and successfully launched in Vaishali district          quality service delivery.
in Bihar, now the sixth state of India to
undertake MAPEDIR.                                      For the first time, financial resources are
                                                        available in the country to implement key
At the macro-level, MAPEDIR’s next phase will           interventions for maternal, newborn and child
include inquiries of perinatal deaths and expansion     health. More significantly, the message from
to facility-based inquiries. Eventually, it will        the grassroots is beginning to be heard evoking
also link up with the Integrated Management of          support at the highest policymaking levels. Under
Neonatal and Childhood Illnesses (IMNCI) – the          the National Rural Health Mission (2005–2012)
newborn-centric Indian adaptation of the global         and the RCH Programme, Phase II (2005–2010),
IMCI (Integrated Management of Childhood                the Government of India has adopted four key
Illness) model – when several initiatives are           strategies to reduce maternal deaths. These are
brought together in optimal synergy to accelerate       essential obstetric and newborn care for all,
the pace.                                               skilled attendance at every birth, emergency
                                                        obstetric care for those with complications,
To make a further dent on India’s MMR, the good         and referral services.
practices from MAPEDIR districts will have to be
scaled up to include other states and districts         However, it is not yet celebration time. India
where women are at acute risk during pregnancy          has a long way to go. It still accounts for nearly
and childbirth. It is also equally important to learn   15 per cent of the global onus of maternal
from the experiences in the field. Recent data          deaths every year. The battle to save mothers’
indicates that even in states with relatively poor      lives is far from over, especially in the country’s
health services, institutional deliveries are going     rural hinterland where maternal mortality is
up. The retrospective assessment of causes and          at its grimmest. Yet the sparks of hope are
bottlenecks at the community level is generating        unmistakable. The number of Primary Health
evidence to fast-track decision-making and better       Centres providing 24 hours delivery services is
                                                        going up. Training sessions are taking place to
                                                        expand the cadre of skilled attendants at birth.
   “In the days ahead, our biggest challenge will be    FRUs are being equipped to provide emergency
   to make sure that there are enough institutions      obstetric and neonatal care. Professional
   which have the necessary manpower and                Associations such as the Federation of Obstetrics
   facilities to handle obstetric emergencies.”         and Gynaecology Societies of India (FOGSI) have
                                                        come forward to help the Government train MBBS
   Ashok Tiwari                                         doctors in obstetric management skills. These are
   President of Mangalam in Rajasthan’s Dholpur         but a few examples of a movement forward.
   district, which pioneered the 24-hour Obstetric
   Emergency Helpline                                   The global commitment to achieve the target of
                                                        a 75 per cent reduction in maternal mortality by

2015, as set out in the MDG5, provides India an              made under the aegis of the National Rural
extraordinary opportunity to ensure that women               Health Mission, MAPEDIR presents itself
deliver safely. At a time when maternal health               as an exciting tool with enormous potential
is climbing up the policy agenda nationally and              to bring India and the world closer to the goal
internationally, and strategic choices are being             of MDG5.

     » In India, as in the rest of South Asia, maternal mortality remains essentially a predicament of poor
       people, and a product of poor healthcare delivery.
     » where families happen to be constrained by resources along with illiteracy and cultural inhibitions,
       MAPEDIR has proved its potential by turning the spotlight on hitherto unseen and unknown aspects of
       maternal deaths and stirring communities, NGOs, academic institutions, local and state administrations
       as well as governments into concerned, concerted action.
     » MAPEDIR has been instrumental in making many invisible problems visible and fostering wider use of
       governmental programmes and provisions on maternal safety among communities who were unlikely
       to benefit from it in the past.
     » The message from the grassroots has started evoking support at the highest policy making levels,
       and for the first time financial resources are available to implement key interventions for maternal,
       newborn and child health in the country.
     » Nonetheless, although much has been achieved in the backward districts of the states of west Bengal,
       Rajasthan, Madhya Pradesh and Orissa in the form of stepped up health audits and maternal death
       inquiries and notification; 24x7 obstetric helplines and upgraded institutional delivery facilities, much
       still needs to be done to save the lives of mothers in the country’s rural hinterland.
     » Measures needed include simplifying the verbal autopsy questionnaire, regular refresher training
       programmes, diligent overview of the MAPEDIR process, and encompassing more states in the country
       into the MAPEDIR network.
     » Accounting for nearly 15 per cent of the global onus of maternal deaths every year, India, recently
       equipped with the tried and tested tool of MAPEDIR, is taking initiatives which could be replicated and
       contribute substantially towards making the United Nation’s MDG5 of attaining 75 per cent reduction
       in maternity deaths by 2015 a distinct reality.


Annexure 1

 Live births, maternal deaths, maternal mortality ratio in India 2001-2003
 India and Major States                     Sample Female Live Births            Maternal   MMR     95% CI    Lifetime
                                               Population                         Deaths                      Risk(%)
 Assam                                             2,02,943           19,619          96    490   (393-588)       1.6
 Bihar/Jharkhand                                   3,21,721           42,112         156    371   (313-430)       1.7
 Madhya Pradesh/Chhattisgarh                       2,20,269           27,563         104    379   (306-452)       1.6
 Orissa                                            2,54,176           20,914          75    358   (277-439)       1.0
 Rajasthan                                         2,48,891           31,371         140    445   (371-519)       1.9
 Uttar Pradesh/Uttaranchal                         4,62,547           62,659         324    517   (461-573)       2.4
 EAG AND ASSAM SUBTOTAL                          17,10,547          2,04,238         895    438   (410-467)       1.8
 Andhra Pradesh                                    2,51,511           19,152          37    195   (132-257)       0.5
 Karnataka                                         2,99,571           24,875          57    228   (169-287)       0.7
 Kerala                                            2,74,990           16,448          18    110    (59-161)       0.2
 Tamil Nadu                                        2,98,726           19,689          26    134    (83-185)       0.3
 SOUTH SUBTOTAL                                  11,24,798            80,164         139    173   (144-202)       0.4
 Gujarat                                           2,19,783           21,220          37    172   (116-228)       0.6
 Haryana                                           1,63,710           17,075          28    162   (102-223)       0.6
 Maharashtra                                       2,66,750           20,982          31    149    (97-201)       0.4
 Punjab                                            1,42,595           11,090          20    178   (100-257)       0.5
 west Bengal                                       3,90,702           29,972          58    194   (144-243)       0.5
 Other                                           10,20,698            74,890         176    235   (200-269)       0.6
 OTHER SUBTOTAL                                  22,04,238          1,75,229         349    199   (178-220)       0.6
 INDIA TOTAL                                     50,39,583          4,59,631       1,383    301   (285-317)       1.0
Sample registration system Maternal mortality trends-causes in India 1997-2003

Annexure 2

 Anaemia among pregnant women, currently married (15-44 years), (percentage), 2002
 S.No.           State/UTs                                              Severe                   Moderate                          Total
 1               Andhra Pradesh                                                3                         31                           34
 2               Arunachal Pradesh                                             -                            -                              -
 3               Assam                                                         -                            -                              -
 4               Bihar                                                         1                         35                           36
 5               Chhattisgarh                                                  5                         41                           46
 6               Delhi                                                         -                            -                              -
 7               Goa                                                           -                            -                              -
 8               Gujarat                                                       1                         39                           40
 9               Haryana                                                       3                         52                           55
 10              Himachal Pradesh                                              2                         32                           34
 11              Jammu and Kashmir                                             -                            -                              -
 12              Jharkhand                                                     0                         31                           31
 13              Karnataka                                                     2                         24                           26
 14              Kerala                                                        1                           3                           4
 15              Madhya Pradesh                                                2                         38                           40
 16              Maharashtra                                                   2                         56                           58
 17              Manipur                                                       -                            -                              -
 18              Meghalaya                                                     -                            -                              -
 19              Mizoram                                                       -                            -                              -
 20              Nagaland                                                      -                            -                              -
 21              Orissa                                                        4                         30                           34
 22              Punjab                                                        4                         50                           54
 23              Rajasthan                                                     3                         36                           39
 24              Sikkim                                                        -                            -                              -
 25              Tamil Nadu                                                    1                         24                           25
 26              Tripura                                                       -                            -                              -
 27              Uttar Pradesh                                                 3                         37                           40
 28              Uttaranchal                                                   1                         26                           27
 29              west Bengal                                                   8                         16                           24
 30              Andaman and Nicobar Islands                                   -                            -                              -
 31              Chandigarh                                                    -                            -                              -
 32              Dadra and Nagar Haveli                                        -                            -                              -
 33              Daman and Diu                                                 -                            -                              -
 34              lakshadweep                                                   -                            -                              -
 35              Pondicherry                                                   -                            -                              -
                 INDIA                                                         3                         33                           36
Source: International Institute for Population Sciences, (2004). National Dissemination Seminar on Reproductive and Child Health Project
(Phase 1, Round 2, 2002) Results, New Delhi, 2004 Jan. 27-28. Fifth Session: Reproductive and Child Health Services, Mumbai. p.145.

Fast facts
S. No.   Statistics                                        India    West Rajasthan    Orissa   Madhya
                                                                   Bengal                      Pradesh
1        Total population (Census 2001) (in million)   1,028.61     80.18    56.51    36.80     60.35
2        Decadal growth (Census 2001) (%)                21.54      17.77    28.41    16.25     24.26
3        Crude birth rate (SRS 2005)                     23.80      18.80    28.60    22.30     29.40
4        Crude death rate (SRS 2005)                       7.60      6.40    38.00     9.50      9.00
5        Total fertility rate (SRS 2004)                   2.90      2.20     3.70     2.70      3.70
6        Infant mortality rate (SRS 2005)                58.00      38.00    68.00    75.00     76.00
7        Maternal mortality ratio                       301.00     194.00   445.00   358.00    379.00
         (SRS 2001-2003)
8        Sex ratio (Census 2001)                        933.00     934.00   921.00   972.00    919.00
9        Population below poverty line (%)               26.10      27.02    15.28    47.15     37.43
10       Scheduled caste population (in million)         24.20      18.45     9.69    34.80      9.16
11       Scheduled tribe population (in million)         84.33       4.41     7.10              12.23
12       Female literacy rate (Census 2001) (%)          54.28      60.22    44.34    50.97     50.28

Health infrastructure
                          West Bengal               Rajasthan                  Orissa              Madhya Pradesh
Item                Required     In position   Required   In position   Required   In position   Required   In position
Sub-centre              12,101      10,356       9,554       10,512       7,283         5,927     10,402        8,874
Primary Health           1,993          922      1,555        1,713       1,171         1,279      1,670        1,192
Community                 498           346        388          325         292          231         417          229
Health Centre
Multipurpose            11,278       9,900      12,225       11,425       7,206         6,768     10,066        9,345
at Sub Centres
and PHCs
Health worker           10,356       5,178      10,512        2,528       5,927         3,392      8,874        7,298
(Male) MPw(M)
at Sub Centres
Health Assistant          922        1,227       1,713        1,358       1,279          726       1,192        1,074
(Female)/lHV at
Health                    922           550      1,713          714       1,279          168       1,192        1,168
Assistant (Male)
at PHCs
Doctor at PHCs            922           811      1,713        1,316       1,279         1,353      1,192          839
Obstetricians             346           346        325          109         231           NA         229            13
at CHCs
Physicians at             346             0        325          206         231           NA         229            12
Paediatricians            346           278        325            76        231           NA         229            12
at CHCs
Total specialists        1,384          624      1,300          592         924           NA         916            49
at CHCs
Radiographers              49            30        325          269         231             8        229           NA
Pharmacist               1,268       1,341       2,038        2,355       1,510         1,984      1,421          216
laboratory               1,268       1,031       2,038        2,065       1,510          311       1,421          386
Nurse/Midwife            3,344          858      3,988        8,425       2,896          637       2,795          902

united nations Children’s Fund
73, lodi Estate
new Delhi, inDia

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